Division 1 GENERAL INFORMATION *

Name(s) of the affected person(s), address(es), tax identification number(s) (TIN)(s): …

Member State of residence for tax purposes of the affected person(s): …

Member States concerned: …

Full address and details of a contact person for the affected person(s), including phone number and email address: …

Names and details of the affected person's counsel (if applicable): …