ANNEX IV
Notification template for the exchange of information in relation to passport applications by e-money institutions using distributors
1) | Home Member State | |||||||||||||||||
2) | Host Member State in which e-money services are to be provided | |||||||||||||||||
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 e-money institution | DD/MM/YY | ||||||||||||||||
5) | Type of application | ☐ First application ☐ Change to previous application ☐ Additional distributors ☐ Distributor 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) | Name of the e-money institution | |||||||||||||||||
8) | Head office address of the e-money institution | |||||||||||||||||
9) | Unique identification number of the 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 e-money institution (where available) | |||||||||||||||||
11) | Home Member State authorisation number of the e-money institution (where applicable) | |||||||||||||||||
12) | Contact person within the e-money institution | |||||||||||||||||
13) | Email of the contact person within the e-money institution | |||||||||||||||||
14) | Telephone number of the contact person within the e-money institution | |||||||||||||||||
15) | Distributor details: If legal person: Name
Telephone number
If natural person: Name, date and place of birth
| |||||||||||||||||
16) | Electronic money services to be provided by the distributor | ☐ Distribution ☐ Redemption of electronic money | ||||||||||||||||
17) | Description of the internal control mechanisms that will be used by the e-money institution/distributor in order to comply with the obligations in relation to the prevention of money laundering and terrorist financing under Directive (EU) 2015/849. | |||||||||||||||||
18) | In case of outsourcing of operational functions of e-money services: Name and address of the entity to which operational functions are to be outsourced Contact details (email and telephone number) of a contact person within the entity to which operational functions are to be outsourced Type and exhaustive description of the operational functions outsourced |