ANNEX V
Form to be used for reporting data for information and statistical purposes
Payment institutions headquartered in a Member State and providing payment services in a different Member State via agents or branches or electronic money institutions providing services via agents, branches or distributors must provide the following data when required by the host competent authority to enable the host authority to receive regular information on the activities carried out in its country.
Table 1. General information on the payment institution/electronic money institution
1)
Name of the payment institution/electronic money institution
2)
Type of institution
☐ Payment institution
☐ Electronic money institution
3)
Head office address of the payment institution/electronic money institution
4)
Unique identification number of the payment institution/electronic money institution in the format of the home Member State (where applicable)
5)
Legal entity identifier (LEI) of the payment institution/electronic money institution (where available)
6)
Home Member State authorisation number of the payment institution/electronic money institution (where applicable)
7)
Contact person within the payment institution/electronic money institution (where available, please provide contact details of the appointed contact person in the host Member State)
Name:
Role:
Email:
Telephone:
8)
Payment services to be provided
☐ Services enabling cash to be placed in a payment account and all the operations required to operate a payment account
☐ Services enabling cash withdrawals from a payment account and all the operations required to operate a payment account
Execution of payment transactions, including transfers of funds on a payment account with the user’s payment provider or with another payment service provider:
Execution of direct debits, including one-off direct debits ☐
Execution of payment transactions through a payment card or a similar device ☐
Execution of credit transfers, including standing orders ☐
Execution of payment transactions where the funds are covered by a credit line for a payment service user:
Execution of direct debits, including one-off direct debits ☐
Execution of payment transactions through a payment card or a similar device ☐
Execution of credit transfers, including standing orders ☐
Including granting of credit in accordance with Article 18(4) of Directive (EU) 2015/2366? ☐ Yes ☐ No
☐ Issuing of payment instruments
☐ Acquiring of payment transactions
Including granting of credit in accordance with Article 18(4) of Directive (EU) 2015/2366? ☐ Yes ☐ No
☐ Money remittance
☐ Payment initiation services
☐ Account information services
9)
Electronic money services to be provided (applicable only to electronic money institutions)
☐ Distribution of electronic money
☐ Redemption of electronic money
10)
Name and address of the 10 largest agents in the host Member State by value of transactions
Agent 1
Agent 2
…
Agent 10
11)
Name and address of the 10 largest distributors in the host Member State by e-money distribution/redemption value
Distributor 1
Distributor 2
…
Distributor 10
Table 2. Branches
Number
Total number of branches and their addresses, where applicable
Total number of employees of the branches, where applicable
Table 3. Agents
Under freedom to provide services (FOS)
Under the right of establishment (FOE)
Number of agents enrolled in the reporting period
Total number of agents at the end of the reporting period
Table 4. Customers/payment service users
Registered in the reporting period
At the end of the reporting period
Number of customers (framework contracts)
Number of payment service users (single payment transactions)
Table 5. Card-based payment instruments
Number of
Credit cards
Revolving cards
Debit cards
Prepaid cards
Other (please specify)
Issued in the reporting period
Outstanding at the end of the period
Credit cards
Revolving cards
Debit cards
Prepaid cards
Other (please specify)
Value of card-based payment transactions executed through
Table 6. Payment accounts
Payment accounts
Opened in the reporting period
Accessed in the reporting period
Total number of payment accounts operated/maintained in the host Member State
Total number of payment accounts accessed in the host Member State
Table 7. Automated teller machines (ATMs)
Number
Amount
Number of ATMs operated/managed by the payment institution
n.a.
Cash withdrawals
Cash placed in payment accounts
Table 8. Complaints
Agents (FOS)
Agents (FOE)
Branches
Aggregated number of complaints received from payment service users within the reporting period
Table 9. Total fraudulent transactions
Volume
Gross value
Total fraudulent payment transactions
Table 10. Notifications to the financial intelligence unit in the host Member State
Volume
Number of suspicious transaction reports sent to the financial intelligence unit
Table 11. Payment transactions in and out of the host Member State
Volume
Value
Agents (FOS)
Agents (FOE)
Branch
TOTAL
Agents (FOS)
Agents (FOE)
Branch
TOTAL
Payment services as referred to in Annex I to Directive (EU) 2015/2366
In
Out
In
Out
In
Out
In
Out
In
Out
In
Out
In
Out
In
Out
1
2
3a
3b
3c
4a
4b
4c
5 (issuing payment instruments)
5 (acquiring payment transactions)
6
7
Table 12. Country of destination of payment transactions OUT (disclose only countries that account for > 10 % of the total value)
Agents (FOE)
Agents (FOE)
Branch
Payment services as referred to in Annex I to Directive (EU) 2015/2366
Country 1
Country 2
…
Country 1
Country 2
…
Country 1
Country 2
…
1
2
3a
3b
3c
4a
4b
4c
5 (issuing payment instruments)
5 (acquiring payment transactions)
6
7
Table 13. Country of origin of payment transactions IN (disclose only countries that account for > 10 % of the total value)
Agents (FOE)
Agents (FOE)
Branch
Payment services as referred to in Annex I to Directive (EU) 2015/2366
Country 1
Country 2
…
Country 1
Country 2
…
Country 1
Country 2
…
1
2
3a
3b
3c
4a
4b
4c
5 (issuing payment instruments)
5 (acquiring payment transactions)
6
7
Table 14. Payment transactions broken down by distribution channel
Volume
Value
Payment services as referred to in Annex I to Directive (EU) 2015/2366
Face to face
Online
Mobile
ATM
Phone
Other
Face to face
Online
Mobile
ATM
Phone
Other
1
2
3a
3b
3c
4a
4b
4c
5 (issuing payment instruments)
5 (acquiring payment transactions)
6
7
Table 15. E-money services
Amount
E-money distributed during the reporting period in the host Member State
E-money redeemed during the reporting period in the host Member State
Table 16. E-money distributors
Under the freedom to provide services (FOS)
Under the right of establishment (FOE)
Number of distributors enrolled in the reporting period
Total number of distributors at the end of the reporting period