# ANNEX IV
**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)*
Notification of an infringement or suspected infringement
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, please find below information on \[an infringement/a suspected infringement\].
\[Please provide all indispensable information on the infringement/suspected infringement, which must include the type of infringement and any action taken by your competent authority, including any precautionary measures or penalties\]
...
...
...
...
\[Please provide any other information on the infringement/suspected infringement that could be of interest and benefit to the notified competent authority\]
...
...
...
...
\[Please add any further comments on the confidentiality and potential use of the information provided\]
...
...
...
...
Yours sincerely,
\[signature\]