Claim FormCOMPLAINT SUBMISSION FORMTo be submitted by the customer to the provider of crypto-asset services Please upload a copy of your existing contract with us to proceed with the complaint submission*. Upload Contract: 1.a Complainant’s Information Entity Name: Full Name*: EUID or National ID Number: Address (Street, House Number)*: Postal Code*: City: Country*: Phone*: Email Address*: 1.b Contact Details (if different from 1.a) Last Name: First Name: Address (Street, House Number): Postal Code: City: Country: Phone: Email Address: 2.a Information on the Legal Representative (if applicable) Attach a power of attorney or other official document proving authorization to act as a representative*: Upload Document: Entity Name: Full Name: Registration Number and LEI (if available): Address (Street, House Number): Postal Code: City: Country: Phone: Email Address: 2.b Contact Details (if different from 2.a) Last Name/Entity Name: First Name: Address (Street, House Number): Postal Code: City: Country: Phone: Email Address: 3. Complainant’s Statement 3.a Complete details of the crypto-asset service related to the complaint Details of the crypto-asset service*: 3.b Description of the Complaint Description of the Complaint*: Upload Supporting Documents: Upload Files: 3.d Description of any damage, loss, or disadvantage suffered (if applicable) Description of damage, loss, or disadvantage: 3.e Additional comments or relevant information (if applicable) Additional comments: I confirm that I have read and agree to the Privacy Policy and consent to the sharing of my submitted data with the responsible third party for the purpose of processing my complaint*.
