Annex IV Notification template for the exchange of information in relation to passport applications by e-money institutions using distributors
United Kingdom
| 1) | Home Member State | |
| 2) | Host Member State in which e-money services are to be provided | |
| 3) | Name of the competent authority of the home Member State | |
| 4) | Date of receipt by the competent authority of the home Member State of the complete and accurate application from the e-money institution | DD/MM/YY |
| 5) | Type of application | ☐ First application ☐ Change to previous application ☐ Additional distributors ☐ Distributor deactivation |
| 6) | Nature of the application (assessment of the competent authority of the home Member State) | ☐ Right of establishment ☐ Freedom to provide services, based on the following circumstances: … … … |
| 7) | Name of the e-money institution | |
| 8) | Head office address of the e-money institution | |
| 9) | Unique identification number of the 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 e-money institution (where available) | |
| 11) | Home Member State authorisation number of the e-money institution (where applicable) | |
| 12) | Contact person within the e-money institution | |
| 13) | Email of the contact person within the e-money institution | |
| 14) | Telephone number of the contact person within the e-money institution | |
| 15) | Distributor details:
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| 16) | Electronic money services to be provided by the distributor | ☐ Distribution ☐ Redemption of electronic money |
| 17) | Description of the internal control mechanisms that will be used by the e-money institution/distributor in order to comply with the obligations in relation to the prevention of money laundering and terrorist financing under Directive (EU) 2015/849. | |
| 18) | In case of outsourcing of operational functions of e-money services:
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