Customer complaint form

Please fill out the form

1. Personal data of the complainant

LAST NAME/LEGAL ENTITY NAME*

FIRST 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*

2.Personal data of the legal representative (if applicable) (a power of attorney or other official document as proof of the appointment of the representative)

LAST NAME/LEGAL ENTITY NAME

FIRST NAME

REGISTRATION NUMBER AND LEI (IF AVAILABLE)

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 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, etc) *

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

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)*

Please, upload here:
1) Power of attorney or other relevant document (if applicable);
2) Copy of the contractual documents of the transactions to which the complaint relates;
3) Other documents supporting the complaint.*

Upload up to 10 supported files. Max 10 MB per file.