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 authorities 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 authorities 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-asset; notification to EBA of product intervention measures pursuant to Article 105(3) of Regulation (EU) 2023/1114, for asset-referenced tokens 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-asset white papers, of issuers of asset-referenced tokens and e-money tokens, and of crypto-asset service providers, 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 authorities 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 data 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 authorities in accordance with Regulation (EU) 2016/679 of the European Parliament and of the Council. In particular, ESMA, EBA and the relevant competent authorities shall ensure that all relevant information on the processing of personal data is provided to data subjects in accordance with Section 2 ‘Information and access to personal data’ of Chapter III ‘Rights of the data subject’ of those Regulations. Yours sincerely, [signature]