Annex I

Form for a request for cooperation or exchange of information

1. Request for cooperation and exchange of information

   1. Reference number: Date: General information FROM: Member State: Submitting Body: Address: (Contact details of the contact point designated in accordance with Article 2 of Implementing Regulation (EU) 2024/2494) Name: Telephone: Email: TO: Member State: Receiving Body: Address: (Contact details of the contact point designated in accordance with Article 2 of Implementing Regulation (EU) 2024/2494) Name: Telephone: Email: Dear [insert appropriate name] In accordance with Article 4 of Implementing Regulation (EU) 2024/2494 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 cooperation and exchange of information between 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; and EBA and ESMA, your cooperation is sought in relation to the matter(s) specified below. Type of request or notification Please tick the appropriate box(es) notification to ESMA and EBA about requests of assistance between national 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; with regard to on-site inspections or investigations pursuant to Article 95(4) of Regulation (EU) 2023/1114; request to ESMA and EBA to coordinate the investigation or inspection pursuant to Article 95(5) of Regulation (EU) 2023/1114; communication to ESMA of situations of rejected or not acted upon requests for cooperation or exchange of information, pursuant to Article 95(6) of Regulation (EU) 2023/1114; communication to EBA of situations of rejected or not acted upon requests for cooperation or exchange of information, pursuant to Article 95(7) of Regulation (EU) 2023/1114; notification to ESMA or to EBA of precautionary measures pursuant to Article 102 of Regulation (EU) 2023/1114; notification to ESMA of product intervention measures pursuant to Article 105(3) and (4) of Regulation (EU) 2023/1114, for 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;; notification to EBA of product intervention measures pursuant to Article 105(3) of Regulation (EU) 2023/1114, for asset-referenced tokensmeans a type of crypto-asset that is not an electronic money token and that purports to maintain a stable value by referencing another value or right or a combination thereof, including one or more official currencies; and e-money tokens; communication to ESMA and EBA of information on the complaints-handling procedures pursuant to Article 108(2) of Regulation (EU) 2023/1114; communication to ESMA of data and information to compile the Register of 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; white papers, of issuersmeans a natural or legal person, or other undertaking, who issues crypto-assets; of asset-referenced tokensmeans a type of crypto-asset that is not an electronic money token and that purports to maintain a stable value by referencing another value or right or a combination thereof, including one or more official currencies; and e-money tokens, and of crypto-asset service providersmeans a legal person or other undertaking whose occupation or business is the provision of one or more crypto-asset services to clients on a professional basis, and that is allowed to provide crypto-asset services in accordance with Article 59;, pursuant to Article 109(1) of Regulation (EU) 2023/1114; notifications to ESMA of the measures listed in Article 94(1), point (b), (c), (f), (l), (m), (n), (o) or (t), and of any public precautionary measures taken pursuant to Article 102, in accordance with Article 109(6) of Regulation (EU) 2023/1114; communication to ESMA for the establishment of the ESMA Register on non-compliant entities providing crypto asset services, pursuant to Article 110 of Regulation (EU) 2023/1114; reporting of administrative penalties and other administrative measures by 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; to ESMA and EBA, pursuant to Article 115 of Regulation (EU) 2023/1114; Any other notification, provision of information or request for information relevant in accordance with Article 96 of Regulation (EU) 2023/1114. Information on the notification or reasons for the request The notification/request concerns [choose ‘notification’ or ‘request’ according to the selection made above] … … … [insert the description of the subject matter of the notification or request, the purpose for which the cooperation or exchange of information is sought or facts underlying the request for coordinating an investigation and explanation for its helpfulness] Further to … … … [if applicable, insert details of the previous notification or request in order to enable it to be identified] The information included in this notification/request [choose the correct option] shall be kept confidential in accordance with Article 10 of Implementing Regulation (EU) 2024/2494 and shall be subject to the requirements of professional secrecy in accordance with Article 100 of Regulation (EU) 2023/1114. Any personal datameans personal data as defined in Article 4, point (1), of Regulation (EU) 2016/679; provided shall be processed by ESMA or EBA in accordance with Regulation (EU) 2018/1725 of the European Parliament and of the Council and by 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; in accordance with Regulation (EU) 2016/679 of the European Parliament and of the Council. In particular, ESMA, EBA and 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 those Regulations. Yours sincerely, [signature]