ANNEX V
Notification template for the exchange of information in relation to freedom to provide services applications with no agent or distributor
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□First application ☐ Change□Change to previous application ☐ End□End of business activity/cessation
6) | Type of Institution | ☐ Payment□Payment Institution ☐ E-Money□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 |
18) | In case of outsourcing of operational functions of payment/e-money services: |
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□Issuing of electronic money ☐ Distribution□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 |