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1/9

Last name (for natural persons) or Legal entity name (Complainant)

First name (for natural persons) (Complainant)

EUID or, if not available, national Registration or ID number (for individuals); Legal Entity Identifier (LEI) or registration number (for legal entities) (Complainant)

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2/9

Address (street, number, floor; for legal entities, registered office) (Complainant)

Postcode (Complainant)

City (Complainant)

Country (Complainant)

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3/9

Telephone number (Complainant)

Email address (Complainant)

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4/9

Last name (for natural persons) or Legal entity name of the representative

First name (for natural persons) of the representative

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5/9

Address (street, number, floor; for legal entities, registered office) of the representative

Postcode of the representative

City of the representative

Country of the representative

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6/9

Telephone number of the representative

Email address of the representative

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7/9

Basis of representation (e.g., power of attorney or other official document, to be provided as an attachment)

Full reference of the crypto-asset service to which the complaint relates (e.g., name of the service, transaction references)

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8/9

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

Requirements of the complainant and description of damage, loss, or detriment caused (where relevant)

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9/9

Date of complaint submission

Place of complaint submission

Supporting documents