Complaint submission form

Complaint Submission Form

For submissions by a complainant under Article 71 of the Markets in Crypto-Assets Regulations (MiCAR)

1a. Personal data of the complainant

Last name / legal entity name

First name

Registration or ID number

LEI number (if available)

Client reference (if available)

Address (for firms registered office)

Street, Number, Floor

Postcode

City

Country

Telephone

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

Last name / legal entity name

First name

Address (for firms registered office)

Street, Number, Floor

Postcode

City

Country

Telephone

2.a Personal data of the legal representative (if applicable)

Please supply a power of attorney or other official document as proof of the appointment of the representative if this section is completed.

Last name / legal entity name

First name

Registration or ID number

LEI number (if available)

Address (for firms registered office)

Street, Number, Floor

Postcode

City

Country

Telephone

2.b Contact details of the legal representative (if different from 1.a)

Last name / legal entity name

First name

Address (for firms registered office)

Street, Number, Floor

Postcode

City

Country

Telephone

3. Information about the complaint

Please select the IP Token (IPT) that this complaint relates to

3.a. Full reference of the crypto-asset service or agreement to which the complaint relates (i.e. name of the crypto-asset service provider, crypto-asset service reference number, or other references of the relevant transactions…)

3.b Description of the complaint’s subject-matter
Please provide documentation supporting any facts mentioned.

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

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

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

4. Supporting documents

Please note the maximum file size for uploads is 10MB.

Power of attorney or other relevant document:

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