# ANNEX — Template that issuers of asset-referenced tokens and, where applicable third-party entities, shall make available to holders of asset-referenced tokens the submission of complaints **Commission Delegated Regulation (EU) 2025/293 · binding · OJ L, 2025/293, 13.2.2025 · dated 30 Sep 2024 [in force]** *In force · Commission Delegated Regulation (EU) 2025/293, OJ L, 2025/293, 13.2.2025 · Checked against EUR-Lex on 26 Oct 2026 · [Official source](https://eur-lex.europa.eu/eli/reg_del/2025/293/oj/eng)* #### SUBMISSION OF A COMPLAINT #### 1.a. Information about the complainant | LAST NAME/LEGAL ENTITY NAME | FIRST NAME | REGISTRATION NUMBER | LEGAL ENTITY IDENTIFIER (IF AVAILABLE) | CUSTOMER REFERENCE (IF AVAILABLE) | | --- | --- | --- | --- | --- | | | | | | |

ADDRESS:

STREET, NUMBER, FLOOR

(In case of legal entity, address of 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

(In case of legal entity, address of 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) | LAST NAME/LEGAL ENTITY NAME | FIRST NAME | REGISTRATION NUMBER | LEGAL ENTITY IDENTIFIER (IF AVAILABLE) | | --- | --- | --- | --- | | | | | |

ADDRESS:

STREET, NUMBER, FLOOR

(In case of legal entity, address of 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

(In case of legal entity, address of registered office)

POSTCODE

CITY

COUNTRY

TELEPHONE

EMAIL ADDRESS

#### 3. Information about the complaint #### 3.a. Full reference of the issuance, offer or seeking of admission to trading of an asset-referenced tokens or agreement to which the complaint relates (i.e. name of the issuers of asset-referenced tokens, Asset-Referenced Tokens 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 Documentation provided _(please check the appropriate box):_

Power of attorney or other relevant document
Copy of the contractual documents of the investments to which the complaint relates
Other documents supporting the complaint: