ANNEX V
Form to be used for reporting data for information and statistical purposes
Payment institutions headquartered in a Member State and providing payment services in a different Member State via agents or branches or electronic money institutions providing services via agents, branches or distributors must provide the following data when required by the host competent authority to enable the host authority to receive regular information on the activities carried out in its country.
Table 1. General information on the payment institution/electronic money institution
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1) |
Name of the payment institution/electronic money institution |
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2) |
Type of institution |
☐ Payment institution ☐ Electronic money institution |
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3) |
Head office address of the payment institution/electronic money institution |
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4) |
Unique identification number of the payment institution/electronic money institution in the format of the home Member State (where applicable) |
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5) |
Legal entity identifier (LEI) of the payment institution/electronic money institution (where available) |
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6) |
Home Member State authorisation number of the payment institution/electronic money institution (where applicable) |
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7) |
Contact person within the payment institution/electronic money institution (where available, please provide contact details of the appointed contact person in the host Member State) |
Name: Role: Email: Telephone: |
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8) |
Payment services to be provided |
☐ Services enabling cash to be placed in a payment account and all the operations required to operate a payment account ☐ Services enabling cash withdrawals from a payment account and all the operations required to operate a payment account Execution of payment transactions, including transfers of funds on a payment account with the user’s payment provider or with another payment service provider: Execution of direct debits, including one-off direct debits ☐ Execution of payment transactions through a payment card or a similar device ☐ Execution of credit transfers, including standing orders ☐ Execution of payment transactions where the funds are covered by a credit line for a payment service user: Execution of direct debits, including one-off direct debits ☐ Execution of payment transactions through a payment card or a similar device ☐ Execution of credit transfers, including standing orders ☐ Including granting of credit in accordance with Article 18(4) of Directive (EU) 2015/2366? ☐ Yes ☐ No ☐ 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 ☐ Money remittance ☐ Payment initiation services ☐ Account information services |
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9) |
Electronic money services to be provided (applicable only to electronic money institutions) |
☐ Distribution of electronic money ☐ Redemption of electronic money |
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10) |
Name and address of the 10 largest agents in the host Member State by value of transactions |
Agent 1 Agent 2 … Agent 10 |
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11) |
Name and address of the 10 largest distributors in the host Member State by e-money distribution/redemption value |
Distributor 1 Distributor 2 … Distributor 10 |
Table 2. Branches
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Number |
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Total number of branches and their addresses, where applicable |
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Total number of employees of the branches, where applicable |
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Table 3. Agents
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Under freedom to provide services (FOS) |
Under the right of establishment (FOE) |
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Number of agents enrolled in the reporting period |
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Total number of agents at the end of the reporting period |
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Table 4. Customers/payment service users
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Registered in the reporting period |
At the end of the reporting period |
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Number of customers (framework contracts) |
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Number of payment service users (single payment transactions) |
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Table 5. Card-based payment instruments
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Number of |
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Credit cards |
Revolving cards |
Debit cards |
Prepaid cards |
Other (please specify) |
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Issued in the reporting period |
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Outstanding at the end of the period |
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Credit cards |
Revolving cards |
Debit cards |
Prepaid cards |
Other (please specify) |
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Value of card-based payment transactions executed through |
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Table 6. Payment accounts
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Payment accounts |
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Opened in the reporting period |
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Accessed in the reporting period |
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Total number of payment accounts operated/maintained in the host Member State |
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Total number of payment accounts accessed in the host Member State |
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Table 7. Automated teller machines (ATMs)
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Number |
Amount |
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Number of ATMs operated/managed by the payment institution |
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n.a. |
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Cash withdrawals |
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Cash placed in payment accounts |
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Table 8. Complaints
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Agents (FOS) |
Agents (FOE) |
Branches |
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Aggregated number of complaints received from payment service users within the reporting period |
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Table 9. Total fraudulent transactions
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Volume |
Gross value |
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Total fraudulent payment transactions |
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Table 10. Notifications to the financial intelligence unit in the host Member State
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Volume |
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Number of suspicious transaction reports sent to the financial intelligence unit |
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Table 11. Payment transactions in and out of the host Member State
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Volume |
Value |
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Agents (FOS) |
Agents (FOE) |
Branch |
TOTAL |
Agents (FOS) |
Agents (FOE) |
Branch |
TOTAL |
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Payment services as referred to in Annex I to Directive (EU) 2015/2366 |
In |
Out |
In |
Out |
In |
Out |
In |
Out |
In |
Out |
In |
Out |
In |
Out |
In |
Out |
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1 |
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2 |
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3a |
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3b |
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3c |
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4a |
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4b |
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4c |
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5 (issuing payment instruments) |
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5 (acquiring payment transactions) |
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6 |
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7 |
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Table 12. Country of destination of payment transactions OUT (disclose only countries that account for > 10 % of the total value)
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Agents (FOE) |
Agents (FOE) |
Branch |
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Payment services as referred to in Annex I to Directive (EU) 2015/2366 |
Country 1 |
Country 2 |
… |
Country 1 |
Country 2 |
… |
Country 1 |
Country 2 |
… |
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1 |
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2 |
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3a |
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3b |
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3c |
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4a |
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4b |
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4c |
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5 (issuing payment instruments) |
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5 (acquiring payment transactions) |
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6 |
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7 |
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Table 13. Country of origin of payment transactions IN (disclose only countries that account for > 10 % of the total value)
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Agents (FOE) |
Agents (FOE) |
Branch |
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Payment services as referred to in Annex I to Directive (EU) 2015/2366 |
Country 1 |
Country 2 |
… |
Country 1 |
Country 2 |
… |
Country 1 |
Country 2 |
… |
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1 |
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2 |
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3a |
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3b |
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3c |
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4a |
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4b |
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4c |
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5 (issuing payment instruments) |
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5 (acquiring payment transactions) |
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6 |
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7 |
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Table 14. Payment transactions broken down by distribution channel
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Volume |
Value |
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Payment services as referred to in Annex I to Directive (EU) 2015/2366 |
Face to face |
Online |
Mobile |
ATM |
Phone |
Other |
Face to face |
Online |
Mobile |
ATM |
Phone |
Other |
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1 |
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2 |
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3a |
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3b |
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3c |
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4a |
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4b |
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4c |
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5 (issuing payment instruments) |
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5 (acquiring payment transactions) |
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6 |
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7 |
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Table 15. E-money services
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Amount |
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E-money distributed during the reporting period in the host Member State |
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E-money redeemed during the reporting period in the host Member State |
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Table 16. E-money distributors
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Under the freedom to provide services (FOS) |
Under the right of establishment (FOE) |
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Number of distributors enrolled in the reporting period |
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Total number of distributors at the end of the reporting period |
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