Submission of a complaint

Fields marked with * are required.

1.a Personal data of the complainant

First name / Legal entity name *

Last name

Registration or ID number

LEI (if available)

Client reference (if available)

Address: street, number, floor (for firms: registered office)

Postcode

City

Country

Telephone

Email *

1.b Contact details (fill only if different from 1.a)

First name / Legal entity name

Last name

Address: street, number, floor (for firms: registered office)

Postcode

City

Country

Telephone

2.a Legal representative (if applicable — attach a power of attorney below)

First name / Legal entity name

Last name

Registration number

LEI (if available)

Address: street, number, floor (for firms: registered office)

Postcode

City

Country

Telephone

2.b Representative's contact details (fill only if different from 2.a)

First name / Legal entity name

Last name

Address: street, number, floor (for firms: registered office)

Postcode

City

Country

Telephone

3. Information about the complaint

3.a Full reference of the crypto-asset service or agreement the complaint relates to *

3.b Description of the complaint's subject-matter *

3.c Date(s) of the facts that led to the complaint *

3.d Description of damage, loss or detriment caused (where relevant)

3.e Other comments or relevant information (where relevant)

Supporting documents

Upload documents supporting the complaint (PDF, JPG, PNG, DOCX — max 10 files, 10 MB each, 50 MB total)

Documentation provided (check the appropriate boxes):

Power of attorney or other relevant document

Copy of the contractual documents to which the complaint relates

Other documents supporting the complaint

Confirmation

Full name (complainant / legal representative) *

Place

I confirm that the information provided is true and accurate *

Submission of a complaint

1.a Personal data of the complainant

3. Information about the complaint

Supporting documents

Confirmation

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