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# ANNEX III

**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)*

<a id="annex-iii"></a>Notification of intention to carry out an on-site inspection in the host Member State

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<table>
<tbody>
<tr><td><p><strong>Reference number:</strong></p><p><strong>FROM:</strong></p></td><td><p><strong>Date:</strong></p><p><strong>TO:</strong></p></td></tr>
<tr><td></td><td></td></tr>
<tr><td>Member State:</td><td>Member State:</td></tr>
<tr><td></td><td></td></tr>
<tr><td>Competent authority:</td><td>Competent authority:</td></tr>
<tr><td></td><td></td></tr>
<tr><td>Address:</td><td>Address:</td></tr>
<tr><td></td><td></td></tr>
<tr><td></td><td></td></tr>
<tr><td>Name:</td><td>Name:</td></tr>
<tr><td></td><td></td></tr>
<tr><td>Telephone:</td><td>Telephone:</td></tr>
<tr><td></td><td></td></tr>
<tr><td>Email:</td><td>Email:</td></tr>
<tr><td></td><td></td></tr>
</tbody>
</table>
<!-- /table -->

Dear \[name\]

Under Article 29 of Directive (EU) 2015/2366 on payment services in the internal market, I intend to carry out an on-site inspection in your country, as detailed below.

Information on the payment institution to be inspected:

...

...

...

...

Information on the scope of and plan for the on-site inspection, if possible:

...

...

...

...

Planned dates of the on-site inspection:

...

...

Yours sincerely,

\[signature\]