# ANNEX I **Commission Delegated Regulation (EU) 2021/1722 · binding · OJ L 343, 28.9.2021 · dated 18 Jun 2021 [in force]** *In force · Commission Delegated Regulation (EU) 2021/1722, OJ L 343, 28.9.2021 · Verified 4 Nov 2026 · [Official source](https://eur-lex.europa.eu/eli/reg_del/2021/1722/oj/eng)* Request for cooperation or information exchange

Reference number:

FROM:

Date:

TO:

Member State:Member State:
Competent authority:Competent authority:
Address:Address:
Name:Name:
Telephone:Telephone:
Email:Email:
Dear \[name\], Under Article 29 of Directive (EU) 2015/2366 on payment services in the internal market, we are seeking your input on the matter(s) detailed below. I would be grateful to receive a response to this request by \[insert indicative date for the reply\] or, if that is not possible, for an indication of your estimated date of response. Type of request Please tick the appropriate box(es):
Provision of information☐
On-site inspection☐
Delegation of inspection☐
Other – please provide details below☐
Please provide the main reasons for the request: ... ... ... ... Please provide a detailed description of the information sought: ... ... ... ... Please provide any additional information that could be of interest and could help the authority concerned provide a swift reply: ... ... ... ... If the request is urgent, please explain why it is urgent and why the deadline is short: ... ... ... ... Please add any further comments on data confidentiality and how you expect to use the information provided: ... ... ... ... Yours sincerely, \[signature\]