# ANNEX — TEMPLATE FOR THE FILING OF COMPLAINTS **Commission Delegated Regulation (EU) 2025/294 · binding · OJ L, 2025/294, 13.2.2025 · dated 1 Oct 2024 [in force]** *In force · Commission Delegated Regulation (EU) 2025/294, OJ L, 2025/294, 13.2.2025 · Checked against EUR-Lex on 26 Oct 2026 · [Official source](https://eur-lex.europa.eu/eli/reg_del/2025/294/oj/eng)* **FILING OF A COMPLAINT** _(to be sent by the_ [_client_](https://www.headlesslaw.com/definitions/mica/client) _to the crypto-asset service provider)_ #### 1.a. Information about the complainant Last name/Legal entity name: ...\ First name: ...\ EUID or if not available national Registration or ID number: ...\ Legal Entity Identifier (if available): ...\ Client reference (if available): ...\ Address (street, number, floor) (for legal entities, registered office): ...\ Postcode: ...\ City: ...\ Country: ...\ Telephone: ...\ Email address: … #### 1.b. Contact details (if different from 1.a) Last name/Legal entity name: ...\ First name: ...\ Address (street, number, floor) (for legal entities, registered office): ...\ Postcode: ...\ City: ...\ Country: ...\ Telephone: ...\ Email address: … #### 2.a. Information about the legal representative (if applicable) _(a power of attorney or other official document as proof of the appointment of the representative to be provided as an attachment to this form)_ Last name/Legal entity name: ...\ First name: ...\ Registration number and LEI (if available): ...\ Address (street, number, floor) (For legal entities, registered office)\ ... \ Postcode: ...\ City: ...\ Country: ...\ Telephone: ...\ Email address: … #### 2.b. Contact details (if different from 2.a) Last name/Legal entity name: ...\ First name: ...\ Address: street, number, floor (For firms registered office)\ ... \ Postcode: ...\ City: ...\ Country: ...\ Telephone: ...\ Email: … #### 3. Information about the complaint **3.a. Full reference of the crypto-asset service to which the complaint relates** _(i.e. name of the crypto-asset service provider, crypto-asset service reference number, or other references of the relevant transactions …)_ ... ... ... *** **3.b. Description of the complaint’s subject-matter** ... ... ... Please provide any documentation supporting the facts mentioned. **3.c. Date(s) of the facts that have led to the complaint** ... ... ... **3.d. Description of damage, loss or detriment caused (where relevant)** ... ... ... **3.e. Other comments or relevant information (where relevant)** ... ... ... In \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_(place) on \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_(date) **SIGNATURE**\ **COMPLAINANT/LEGAL REPRESENTATIVE OF THE COMPLAINANT** Documentation provided (please check the appropriate box): | | | | | - | | Power of attorney or other official document as proof of the appointment of the representative | ? | | Copy of the contractual documents of the investments to which the complaint relates | ? | | Other documents supporting the complaint: | ? | ... ... ...