# ANNEX — Form for the notification of information to be provided by certain financial entities **Commission Implementing Regulation (EU) 2025/304 · binding · OJ L, 2025/304, 20.2.2025 · dated 31 Oct 2024 [in force]** *In force · Commission Implementing Regulation (EU) 2025/304, OJ L, 2025/304, 20.2.2025 · Checked against EUR-Lex on 26 Oct 2026 · [Official source](https://eur-lex.europa.eu/eli/reg_impl/2025/304/oj/eng)* 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](https://www.headlesslaw.com/definitions/mica/crypto-asset-service), kindly find attached our notification of our intention to provide crypto-asset services. _Reference number (to be completed by the competent authority):_ Date: FROM Name of the notifying entity: National reference number: Address of the notifying entity: Contact details of designated contact person: Name: Telephone: Email: TO Member State (if applicable): Competent authority: Address: Contact details of the designated contact point: Name: Telephone: Email: \[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. — Person in charge of preparing the notification: Name: Status/position: Telephone: Email: REQUIRED INFORMATION _Programme of operations_ ... 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. _Business continuity_ ... 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. _Detection and prevention of_ _money laundering_ _and_ _terrorist financing_ ... 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. _ICT systems and related security arrangements_ ... 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. _Segregation of clients’ crypto-assets and_ [_funds_](https://www.headlesslaw.com/definitions/mica/funds) ... 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. _Custody and administration policy_ ... 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. _Operating rules of the trading platform and market abuse detection_ ... 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. [_Exchange of crypto-assets for funds_](https://www.headlesslaw.com/definitions/mica/exchange-of-crypto-assets-for-funds) _or other crypto-assets_ ... 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. _Execution policy_ ... 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. _Provision of advice or portfolio management on crypto-assets_ ... 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. _Transfer services_ ... 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. \[_signature of legal representative_]