ANNEX XI

The form’s text as printed in the original act (OJ L 340, 20.12.2017); the consolidated version prints the form only as an image, above.

Form for the communication on a change of branch particulars notification by the competent authority of the home Member State to the competent authority of the host Member State (Article 19(1) of Commission Implementing Regulation (EU) 2017/2382) Reference number: Date: Communication in accordance with Article 35(10) of Directive 2014/65/EU (1) FROM: Member State: Competent authority of the home Member State: Address: Designated contact point: Telephone number: Email: TO: Member State: Competent Authority of the host Member State: Address: Designated contact point: Telephone number: Email: In accordance with Article 35(10) of Directive 2014/65/EU, we wish to inform you that [Name of firm], an investment firm authorised by [Competent Authority of the home Member State], has: (a) amended the investment services and activities/ancillary services being provided by the [name of the branch] established in [name of the host Member State]. (b) changed its branch name from [add old name of the branch] to [add new name] with effect [date of change] (c) changed its branch other contact information to as follows [add any changes to the contact information notified under Part 1 of the form set out in Annex VI to Commission Implementing Regulation (EU) 2017/2382] with effect [date of change] (d) engaged an additional tied agent located in [name of the host Member State] and provide an updated programme of operations (e) changed its own name/address/contact details from [old name/address/contact details of the investment firm] to [new name/address/contact details of the investment firm] with effect [date of change]. Please find attached a copy of the change of investment services and activities particulars notification with the relevant changes. If you have any queries, please do not hesitate to contact us. Yours sincerely, [Signature] (1) Please amend accordingly.