ANNEX I - SUBMISSION OF A COMPLAINT
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Article 7 – Entry into force ⬅️ | ➡️ Retour au sommaire
SUBMISSION OF A COMPLAINT
(to be sent by the client to the crowdfunding service provider)
1.a
Personal data of the complainant
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
1.b
Contact details (if different from 1.a)
LAST NAME/LEGAL ENTITY NAME
FIRST NAME
ADDRESS:
STREET, NUMBER, FLOOR
(for firms registered office)
POSTCODE
CITY
COUNTRY
TELEPHONE
2.a
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
FIRST NAME/LEGAL ENTITY NAME
REGISTRATION NUMBER AND LEI (IF AVAILABLE)
ADDRESS:
STREET, NUMBER, FLOOR
(for firms registered office)
POSTCODE
CITY
COUNTRY
TELEPHONE
2.b
Contact details (if different from 2.a)
LAST NAME/LEGAL ENTITY NAME
FIRST NAME
ADDRESS:
STREET, NUMBER, FLOOR
(for firms registered office)
POSTCODE
CITY
COUNTRY
TELEPHONE
3.
Information about the complaint
3.a
Full reference of the investment or agreement to which the complaint relates (i.e. investment reference number, name of the project owner/company or crowdfunding project, other references of the relevant transactions…)
3.b
Description of the complaint’s subject-matter (please clearly specify the subject matter of the complaint)
Please provide documentation supporting the facts mentioned.
3.c
Date(s) of the facts that have generated the complaint
3.d
Description of damage, loss or detriment caused (where relevant)
3.e
Other comments or relevant information (where relevant)
In
(place)
on
(date)
SIGNATURE
COMPLAINANT/LEGAL REPRESENTATIVE
Documentation provided (please check the appropriate box):
Power of attorney or other relevant document
…
Copy of the contractual documents of the investments to which the complaint relates
…
Other documents supporting the complaint:# Table 1 in anx_1
| SUBMISSION OF A COMPLAINT(to be sent by the client to the crowdfunding service provider) |
|---|
Table 2 in anx_1
| LAST NAME/LEGAL ENTITY NAME | FIRST NAME | REGISTRATION NUMBER AND LEI (IF AVAILABLE) |
|---|---|---|
Table 3 in anx_1
| ADDRESS:STREET, NUMBER, FLOOR(for firms registered office) | POSTCODE | CITY | COUNTRY |
|---|---|---|---|
Table 4 in anx_1
| TELEPHONE |
|---|
Table 5 in anx_1
| LAST NAME/LEGAL ENTITY NAME | FIRST NAME |
|---|---|
Table 6 in anx_1
| ADDRESS:STREET, NUMBER, FLOOR(for firms registered office) | POSTCODE | CITY | COUNTRY |
|---|---|---|---|
Table 7 in anx_1
| TELEPHONE |
|---|
Table 8 in anx_1
| LAST NAME | FIRST NAME/LEGAL ENTITY NAME | REGISTRATION NUMBER AND LEI (IF AVAILABLE) |
|---|---|---|
Table 9 in anx_1
| ADDRESS:STREET, NUMBER, FLOOR(for firms registered office) | POSTCODE | CITY | COUNTRY |
|---|---|---|---|
Table 10 in anx_1
| TELEPHONE |
|---|
Table 11 in anx_1
| LAST NAME/LEGAL ENTITY NAME | FIRST NAME |
|---|---|
Table 12 in anx_1
| ADDRESS:STREET, NUMBER, FLOOR(for firms registered office) | POSTCODE | CITY | COUNTRY |
|---|---|---|---|
Table 13 in anx_1
| TELEPHONE |
|---|
Table 14 in anx_1
Table 15 in anx_1
Table 16 in anx_1
Table 17 in anx_1
Table 18 in anx_1
Table 19 in anx_1
| In | (place) | on | (date) |
|---|---|---|---|
| SIGNATURE |
Table 20 in anx_1
| COMPLAINANT/LEGAL REPRESENTATIVEDocumentation provided (please check the appropriate box): |
|---|