Annex I | FORM FOR REQUEST FOR COOPERATION OR EXCHANGE OF INFORMATION

Request for cooperation or exchange of information

Reference number: Date: General information FROM Member State: Competent Authoritymeans one or more authorities:designated by each Member State in accordance with Article 93 concerning offerors, persons seeking admission to trading of crypto-assets other than asset-referenced tokens and e-money tokens, issuers of asset-referenced tokens, or crypto-asset service providers;designated by each Member State for the application of Directive 2009/110/EC concerning issuers of e-money tokens;: Address: (Contact details of the contact point) Name: Telephone: Email: TO Member State: Competent Authoritymeans one or more authorities:designated by each Member State in accordance with Article 93 concerning offerors, persons seeking admission to trading of crypto-assets other than asset-referenced tokens and e-money tokens, issuers of asset-referenced tokens, or crypto-asset service providers;designated by each Member State for the application of Directive 2009/110/EC concerning issuers of e-money tokens;: Address: (Contact details of the contact point) Name: Telephone: Email: Dear [insert appropriate name] In accordance with Article 3 your input is sought in relation to the matter(s) set out in further detail below. I would be grateful to receive a response to the above request within [provide timeframe based on the type of request] from the receipt of this request. Type of Request Please tick the appropriate box(es)
Supervisory activities (provision of information, taking of a statement)	□
Investigation	□
On-site inspection	□
	□
Urgency of Request Please tick the appropriate box(es)
Non-urgent request	□
Urgent request	□
The [requesting authority] requests the [requested authority] to consider this request as urgent for the following reasons: … … … [please provide, in a clear manner, the reasons underlying the urgency of the request, including if the request was initially made orally] Reasons for the Request … … … [insert provision(s) of the sectoral legislation i) under which the requesting authority is competent to deal with the matter and ii) which may potentially be infringed.] The request concerns cooperation or exchange of information on … … … [insert the description of the subject matter of the request, the purpose for which the cooperation or exchange of information is sought, facts underlying the investigation which form the basis of the request and explanation of how the reply to the requested information or assistance will be useful for fulfilling the duties under Regulation (EU) 2023/1114 of the European Parliament and of the Council(¹)Regulation (EU) 2023/1114 of the European Parliament and of the Council of 31 May 2023 on markets in crypto-assets, and amending Regulations (EU) No 1093/2010 and (EU) No 1095/2010 and Directives 2013/36/EU and (EU) 2019/1937 (OJ L 150, 9.6.2023, p. 40, ELI: http://data.europa.eu/eli/reg/2023/1114/oj).] Further to … … … [if applicable, insert details of any previous request in order to enable it to be identified] Supervisory Activities (provision of information, taking of a statement) Provision of information Please provide a detailed description of the specific information sought with reasons why that information will be of assistance and, if known, a list of the persons who might possess the information sought or the places where such information might be obtained. … … … If the request concerns information relating to a transaction or order in a specific crypto-assetmeans a digital representation of a value or of a right that is able to be transferred and stored electronically using distributed ledger technology or similar technology;, please provide the following information. Product ID: … [insert precise description of the crypto-asset, including the product identifier in accordance with Commission Delegated Regulation establishing technical standards adopted pursuant to Article 68(10)(b) of Regulation (EU) 2023/1114] Person ID: … [insert the identity of any person connected with the transaction or order, including a person dealing in the crypto-asset or on whose behalf the dealing is considered to have taken place. Where available, include any applicable identification code, such as an LEI code or client Id as under Regulation (EU) No 600/2014 of the European Parliament and of the Council(²)Regulation (EU) No 600/2014 of the European Parliament and of the Council of 15 May 2014 on markets in financial instruments and amending Regulation (EU) No 648/2012 (OJ L 173, 12.6.2014, p. 84, ELI: http://data.europa.eu/eli/reg/2014/600/oj).] Dates: … [insert the dates between which transactions or orders in those crypto-assets took place including in the case of a significant period of time, reasons why the entirety of the time period is necessary] If the request concerns information relating to the business or activities of a person, please provide information that makes it possible to identify that person. … … … If there are special considerations regarding the sensitivity of the information sought, please provide an indication of that sensitivity and any special precautions that have to be taken in collecting the information due to considerations relating to the investigation. Please also specify whether the requested authority may reveal the identity of the requesting authority. … … … … Please provide any additional information that is considered relevant. … … … [For example, whether the requesting authority has been or will be in contact with any other authority or law enforcement agency in the Member State of the requested authority in relation to the subject matter of the request or with any other authority which, as far as the requesting authority is aware, has an active interest in the subject matter of the request] Taking of a statement Please indicate: Statement under: □ □ □ Basis of the statement: □ □ Need and purpose of the taking of a statement and, where applicable, of requiring a statement under oath or affirmation: … … … Name of the persons from whom the statement is to be obtained: … … … [insert details of the persons from which the statement will be taken to enable the requested authority to begin the summoning process where applicable] Detailed description of the information sought, including a preliminary list of questions (if available at the time of the request). … … … Any additional information that is considered relevant: … … … [For example, whether the requesting authority’s staff is requesting participation in the taking of the statement, details of the participating officials of the requesting authority, where appropriate, a description of any legal and procedural requirements that must be complied with to ensure the admissibility of the statements made in the jurisdiction of the requesting authority] The opening of an investigation If the request concerns the opening of an investigation on behalf of the requesting authority, please provide information to enable the requested authority to assess whether it may have an interest in entering into a joint investigation, including the requesting authority’s proposal for the investigation, its reasoning for opening the investigation and the perceived benefits to that authority. … … … [including all relevant information that the requested authority needs to be able to provide the necessary assistance by opening an investigation or a joint investigation, as appropriate] The opening of an on-site inspection If the request concerns the opening of an on-site inspection on behalf of the requesting authority, please provide information to enable the requested authority to assess whether it may have an interest in entering into a joint on-site inspection, including the requesting authority’s proposal for the inspection, its reasoning for the inspection and the perceived benefits to that authority. … … … [including all relevant information that the requested authority needs to provide the necessary assistance by opening an on-site inspection or a joint on-site inspection, as appropriate] The information included in this request shall be kept confidential in accordance with Article 11 of this Regulation and Article 100 of Regulation (EU) 2023/1114. The requirements set out in Article 101 of Regulation (EU) 2023/1114 shall be observed with respect to any personal datameans personal data as defined in Article 4, point (1), of Regulation (EU) 2016/679; included in this request. In particular, the relevant competent authoritiesmeans one or more authorities:designated by each Member State in accordance with Article 93 concerning offerors, persons seeking admission to trading of crypto-assets other than asset-referenced tokens and e-money tokens, issuers of asset-referenced tokens, or crypto-asset service providers;designated by each Member State for the application of Directive 2009/110/EC concerning issuers of e-money tokens; shall ensure that all relevant information on the processing of personal datameans personal data as defined in Article 4, point (1), of Regulation (EU) 2016/679; is provided to data subjects in accordance with Section 2 ‘Information and access to personal datameans personal data as defined in Article 4, point (1), of Regulation (EU) 2016/679;’ of Chapter III ‘Rights of the data subject’ of Regulation (EU) 2016/679 of the European Parliament and of the Council(³)Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016 on the protection of natural persons with regard to the processing of personal data and on the free movement of such data, and repealing Directive 95/46/EC (General Data Protection Regulation) (OJ L 119, 4.5.2016, p. 1, ELI: http://data.europa.eu/eli/reg/2016/679/oj).. Yours sincerely, [signature]