Last name/Legal entity name:

First name:

EUID or if not available national Registration or ID number:

Legal Entity Identifier (if available):

Client reference (if available):

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

Postcode:

City:

Country:

Telephone:

Email address:

Last name/Legal entity name:

First name:

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

Postcode:

City:

Country:

Telephone:

Email address:

Last name/Legal entity name:

First name:

Registration number and LEI (if available):

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

Postcode:

City:

Country:

Telephone:

Email address:

Last name/Legal entity name:

First name:

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

Postcode:

City:

Country:

Telephone:

Email:

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 …)

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

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

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

3.e.       Other comments

Please provide any documentation supporting the facts mentioned.