1)

Home Member State

2)

Name of the competent authority of the home Member State

3)

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

4)

Member State where the services are to be provided

5)

Type of application

□First application

□Change to previous application

□End of business activity/cessation

6)

Type of Institution

□Payment Institution

□E-Money Institution

7)

Name of the payment institution/e-money institution

8)

Head office address of the payment institution/e-money institution

9)

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)

10)

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

11)

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

12)

Contact person within the payment institution/e-money institution

13)

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

14)

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

15)

The intended date of start of the provision of payment/e-money services (shall not precede the communication of the decision of the competent authority of the home Member State referred to in Article 28(3) of Directive (EU) 2015/2366

DD/MM/YYYY

16)

Payment services to be provided

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

17)

E-money services to be provided (applicable only to e-money institutions)

□Issuing of electronic money

□Distribution and/or Redemption of electronic money

18)

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