In this act Annex of 1
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
Financial servicesLevel 2RTSMiCAIn forceOfficial source
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: |