In this act Annex V of 6
ANNEX V
Financial servicesLevel 2RTSPSD2In forceOfficial source
Notification template for the exchange of information in relation to freedom to provide services applications with no agent or distributor
| 1) | Home Member State | |
| 2) | Name of the competent authority of the home Member State | |
| 3) | Date of receipt by the competent authority of the home Member State of the complete and accurate application from the payment institution/e-money institution | DD/MM/YY |
| 4) | Member State where the services are to be provided | |
| 5) | Type of application | □First application □Change to previous application □End of business activity/cessation |
| 6) | Type of Institution | □Payment Institution □E-Money Institution |
| 7) | Name of the payment institution/e-money institution | |
| 8) | Head office address of the payment institution/e-money institution | |
| 9) | Unique identification number of the payment institution/e-money institution in the format of the home Member State as specified in Annex I (where applicable) | |
| 10) | Legal Entity Identifier (LEI) of the payment institution/e-money institution (where available) | |
| 11) | Home Member State authorisation number of the payment institution/e-money institution (where applicable) | |
| 12) | Contact person within the payment institution/e-money institution | |
| 13) | Email of the contact person within the payment institution/e-money institution | |
| 14) | Telephone number of the contact person within the payment institution/e-money institution | |
| 15) | The intended date of start of the provision of payment/e-money services (shall not precede the communication of the decision of the competent authority of the home Member State referred to in Article 28(3) of Directive (EU) 2015/2366 | DD/MM/YYYY |
| 16) | Payment services to be provided | 1. □Services enabling cash to be placed on a payment account as well as all the operations required for operating a payment account 2. □Services enabling cash withdrawals from a payment account as well as all the operations required for operating a payment account 3. Execution of payment transactions, including transfers of funds on a payment account with the user's payment provider or with another payment service provider: a) execution of direct debits, including one-off direct debits□ b) execution of payment transactions through a payment card or a similar device□ c) execution of credit transfers, including standing orders□ 4. Execution of payment transactions where the funds are covered by a credit line for a payment service user: a) execution of direct debits, including one-off direct debits□ b) execution of payment transactions through a payment card or a similar device□ c) execution of credit transfers, including standing orders□ Including granting of credit in accordance with Article 18(4) of Directive (EU) 2015/2366:□yes□no 5. □Issuing of payment instruments □Acquiring of payment transactions Including granting of credit in accordance with Article 18(4) of Directive (EU) 2015/2366:□yes□no 6. □Money remittance 7. □Payment initiation services 8. □Account information services |
| 17) | E-money services to be provided (applicable only to e-money institutions) | □Issuing of electronic money □Distribution and/or Redemption of electronic money |
| 18) | In case of outsourcing of operational functions of payment/e-money services: a. Name and address of the entity to which operational functions are to be outsourced b. Contact details (email and telephone number) of a contact person within the entity to which operational functions are to be outsourced c. Type and exhaustive description of the operational functions outsourced |