# Commission Delegated Regulation (EU) 2017/2055 of 23 June 2017 supplementing Directive (EU) 2015/2366 of the European Parliament and of the Council with regard to regulatory technical standards for the cooperation and exchange of information between competent authorities relating to the exercise of the right of establishment and the freedom to provide services of payment institutions (Text with EEA relevance), Annex IV: Notification template for the exchange of information in relation to passport applications by e-money institutions using distributors

Extent: E+W+S+N.I.

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:
a.. If legal person:
i.. Name
ii.. Registered Address(es)
iii.. Unique identification number in the format of the Member State where the distributor is located as specified in Annex I (where applicable)
iv.. Legal Entity Identifier (LEI) of the distributor (where available)
v.. Telephone number
vi.. Email
vii.. Name, place and date of birth of legal representatives
b.. If natural person:
i.. Name, date and place of birth
ii.. Registered Business address(es)
iii.. Unique identification number in the format of the Member State where the distributor is located as specified in Annex I (where applicable)
iv.. Telephone number
v.. Email
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:
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

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Source: https://www.legislation.gov.uk/eur/2017/2055/annex/IV (the official version)
Page: https://openlegislation.uk/eu-regulation-2017-2055/annex-IV
Contains public sector information licensed under the Open Government Licence v3.0. Source: legislation.gov.uk, The National Archives.