Updated 05/02/2025
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PSD2 ToolDelegated Regulation 2017/2055
ANNEX III

ANNEX III - Delegated Regulation 2017/2055

ANNEX III

Notification template for the exchange of information in relation to passport applications by payment institutions and e-money institutions using agents

1)

Home Member State

 

2)

Host Member State in which the agent is to provide payment services

 

3)

Name of the competent authority of the home Member State

 

4)

Date of receipt by the competent authority of the home Member State of the complete and accurate application from the payment institution/e-money institution

DD/MM/YY

5)

Type of application

☐ First application

☐ Change to previous application

☐ Additional agents

☐ Agent deactivation

6)

Nature of the application (assessment of the competent authority of the home Member State)

☐ Right of establishment

☐ Freedom to provide services, based on the following circumstances:

…

…

…

7)

Type of Institution

☐ Payment Institution

☐ E-Money Institution

8)

Name of the payment institution/e-money institution

 

9)

Head office address of the payment/e-money institution

 

10)

Unique identification number of the payment institution/e-money institution in the format of the home Member State as specified in Annex I (where applicable)

 

11)

Legal Entity Identifier (LEI) of the payment institution/e-money institution (where available)

 

12)

Home Member State authorisation number of the payment institution/e-money institution (where applicable)

 

13)

Contact person within the payment institution/e-money institution

 

14)

Email of the contact person within the payment institution/e-money institution

 

15)

Telephone number of the contact person within the payment institution/e-money institution

 

16)

Agent details:

a.

If legal person:

i.

Name

ii.

Registered address(es)

iii.

Unique identification number in the format of the Member State where the agent is located as specified in Annex I (where applicable)

iv.

Legal Entity Identifier (LEI) of the agent (where available)

v.

Telephone number

vi.

Email

vii.

Name, place and date of birth of legal representatives

b.

If natural person:

i.

Name, date and place of birth

ii.

Registered business address(es)

iii.

Unique identification number in the format of the Member State where the agent is located as specified in Annex I (where applicable)

iv.

Telephone number

v.

Email

 

17)

If under the right of establishment, central contact point, if already appointed and/or required by the host authorities in accordance with Article 29(4) of Directive (EU) 2015/2366:

a.

Name of representative

b.

Address

c.

Telephone number

d.

Email

 

18)

Payment services to be provided by the agent

1.

☐ Services enabling cash to be placed on a payment account as well as all the operations required for operating a payment account

2.

☐ Services enabling cash withdrawals from a payment account as well as all the operations required for operating a payment account

3.

Execution of payment transactions, including transfers of funds on a payment account with the user's payment provider or with another payment service provider:

a)

execution of direct debits, including one-off direct debits ☐

b)

execution of payment transactions through a payment card or a similar device ☐

c)

execution of credit transfers, including standing orders ☐

4.

Execution of payment transactions where the funds are covered by a credit line for a payment service user:

a)

execution of direct debits, including one-off direct debits ☐

b)

execution of payment transactions through a payment card or a similar device ☐

c)

execution of credit transfers, including standing orders ☐

Including granting of credit in accordance with Article 18(4) of Directive (EU) 2015/2366: ☐ yes ☐ no

5.

☐ Issuing of payment instruments

☐ Acquiring of payment transactions

Including granting of credit in accordance with Article 18(4) of Directive (EU) 2015/2366: ☐ yes ☐ no

6.

☐ Money remittance

7.

☐ Payment initiation services

8.

☐ Account information services

19)

Description of the internal control mechanisms that will be used by the payment institution/e-money institution/agent in order to comply with the obligations in relation to the prevention of money laundering and terrorist financing under Directive (EU) 2015/849

 

20)

Identity and contact details of directors and persons responsible for the management of the agent engaged

 

21)

For agents other than payment service providers, criteria considered to ensure that directors and persons responsible for the management of the agent to be used in the provision of payment services are fit and proper persons.

a.

☐ Evidence gathered by the Payment Institution attesting that directors and persons responsible for the management of the agent to be used in the provision of payment services are fit and proper persons.

b.

☐ Actions taken by the competent authority in the home Member State pursuant to Article 19(3) of Directive (EU) 2015/2366 to verify the information provided by the payment institution.

22)

In case of outsourcing of operational functions of payment/e-money services:

a.

Name and address of the entity to which operational functions are to be outsourced

b.

Contact details (email and telephone number) of a contact person within the entity to which operational functions are to be outsourced

c.

Type and exhaustive description of the operational functions outsourced