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 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 | ☐ Services enabling cash to be placed on a payment account as well as all the operations required for operating a payment account ☐ Services enabling cash withdrawals from a payment account as well as all the operations required for operating 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 payment transactions where the funds are covered by a credit line for a payment service user:
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 | ||||||||||||
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: 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 |