FILING OF A COMPLAINT

(to be sent by the client to the crypto-asset service provider)

1.a.    Information about the complainant

Last name/Legal entity name:

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First name:

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EUID or if not available national Registration or ID number:

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Legal Entity Identifier (if available):

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Client reference (if available):

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Address (street, number, floor) (for legal entities, registered office):

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Postcode:

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City:

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Country:

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Telephone:

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Email address:

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1.b.    Contact details (if different from 1.a)

Last name/Legal entity name:

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First name:

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Address (street, number, floor) (for legal entities, registered office):

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Postcode:

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City:

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Country:

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Telephone:

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Email address:

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2.a.    Information about the legal representative (if applicable) (a power of attorney or other official document as proof of the appointment of the representative to be provided as an attachment to this form)

Last name/Legal entity name:

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First name:

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Registration number and LEI (if available):

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Address (street, number, floor) (For legal entities, registered office)

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Postcode:

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City:

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Country:

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Telephone:

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Email address:

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2.b.    Contact details (if different from 2.a)

Last name/Legal entity name:

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First name:

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Address: street, number, floor (For firms registered office)

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Postcode:

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City:

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Country:

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Telephone:

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Email:

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3.   Information about the complaint

3.a.    Full reference of the crypto-asset service to which the complaint relates (i.e. name of the crypto-asset service provider, crypto-asset service reference number, or other references of the relevant transactions …)

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3.b.    Description of the complaint’s subject-matter

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Please provide any documentation supporting the facts mentioned.

3.c.    Date(s) of the facts that have led to the complaint

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3.d.    Description of damage, loss or detriment caused (where relevant)

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3.e.    Other comments or relevant information (where relevant)

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In ___________________________________(place) on ____________________(date)

SIGNATURE

COMPLAINANT/LEGAL REPRESENTATIVE OF THE COMPLAINANT

Documentation provided (please check the appropriate box):

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