Canis-cross-border payments.

Complaint Submission Form

FILING OF A COMPLAINT

1.a. Information about the complainant

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 any)

Address:

Street, Number, Floor

Address:

Postcode

City

Country

Telephone

Email Address

Country

Postcode

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

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 any)

Address:

Street, Number, Floor

Address:

Postcode

City

Country

Telephone

Email Address

Postcode

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

First Name

Registration Number and LEI (if available)

Address:

Street, Number, Floor

Address:

Street, Number, Floor

City

Country

Telephone

Please upload a Power of Attorney or other official document as proof of the appointment of the representative.

No File is Chosen

Maximum File Size : 5MB

Supported Files : JPEG, PNG, PDF, Word

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

Last Name/Legal Entity Name

First Name

Registration Number and LEI (if available)

Address:

Street, Number, Floor

Address:

Postcode

City

Country

Telephone

Please upload a Power of Attorney or other official document as proof of the appointment of the representative.

No File is Chosen

Maximum File Size : 5MB

Supported Files : JPEG, PNG, PDF, Word

Postcode

Country

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…)

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

No File is Chosen

Maximum File Size : 5MB

Supported Files : JPEG, PNG, PDF, Word

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 or relevant information (where relevant)

Declaration

Date

Place

Signature (typed full name)

or upload your signature