Annex

Form for the notification of information to be provided by certain financial entities

1. In accordance with Articles 2 and 4 of Commission Implementing Regulation (EU) 2025/304 of 31 October 2024, laying down implementing technical standards for the application of Regulation (EU) 2023/1114 of the European Parliament and of the Council with regard to standard forms, templates and procedures for the notification of certain financial entities of their intention to provide crypto-asset services, kindly find attached our notification of our intention to provide crypto-asset services(¹).

2. 1. Reference number (to be completed by the competent authority):

   2. Date:

   3. FROM

   4. Name of the notifying entity:

   5. National reference number:

   6. Address of the notifying entity:

   7. Contact details of designated contact person:

   8. Name:

   9. Telephone:

   10. Email:

   11. TO

   12. Member State (if applicable):

   13. Competent authority:

   14. Address:

   15. Contact details of the designated contact point:

   16. Name:

   17. Telephone:

   18. Email:

   19. [We,] [notifying entity,] declare that the submitted information is accurate, complete and up-to-date. If some information relates only to a future date, it is explicitly identified in the notification and we undertake to notify the authority in writing without delay if any such information should turn out to be inaccurate, incomplete or misleading. Further, we undertake to inform the competent authority of any change concerning the information provided in this form.

       1. Person in charge of preparing the notification:

   20. Name:

   21. Status/position:

   22. Telephone:

   23. Email:

   24. REQUIRED INFORMATION

   25. Programme of operations

   26. …

   27. Please insert the information referred to in Article 1 of Delegated Regulation (EU) 2025/303, by setting out that information here or making reference to the relevant sections of the notification.

   28. Business continuity

   29. …

   30. Please insert the information referred to in Article 2 of Delegated Regulation (EU) 2025/303, by setting out that information here or making reference to the relevant sections of the notification.

   31. Detection and prevention of money laundering and terrorist financing

   32. …

   33. Please insert the information referred to in Article 3 of Delegated Regulation (EU) 2025/303, by setting out that information here or making reference to the relevant sections of the notification.

   34. ICT systems and related security arrangements

   35. …

   36. Please insert the information referred to in Article 4 of Delegated Regulation (EU) 2025/303, by setting out that information here or making reference to the relevant sections of the notification.

   37. Segregation of clients’ crypto-assets and funds

   38. …

   39. Please insert the information referred to in Article 5 of Delegated Regulation (EU) 2025/303, by setting out that information here or making reference to the relevant sections of the notification.

   40. Custody and administration policy

   41. …

   42. Please insert the information referred to in Article 6 of Delegated Regulation (EU) 2025/303, by setting out that information here or making reference to the relevant sections of the notification.

   43. Operating rules of the trading platform and market abuse detection

   44. …

   45. Please insert the information referred to in Article 7 of Delegated Regulation (EU) 2025/303, by setting out that information here or making reference to the relevant sections of the notification.

   46. Exchange of crypto-assets for funds or other crypto-assets

   47. …

   48. Please insert the information referred to in Article 8 of Delegated Regulation (EU) 2025/303, by setting out that information here or making reference to the relevant sections of the notification.

   49. Execution policy

   50. …

   51. Please insert the information referred to in Article 9 of Delegated Regulation (EU) 2025/303, by setting out that information here or making reference to the relevant sections of the notification.

   52. Provision of advice or portfolio management on crypto-assets

   53. …

   54. Please insert the information referred to in Article 10 of Delegated Regulation (EU) 2025/303, by setting out that information here or making reference to the relevant sections of the notification.

   55. Transfer services

   56. …

   57. Please insert the information referred to in Article 11 of Delegated Regulation (EU) 2025/303, by setting out that information here or making reference to the relevant sections of the notification.

   58. [signature of legal representative]