Data Collection Form for Intent Notification pursuant to Section 25(1) ZAG in conjunction with Section 7 ZAGAnzV (Agent Notification)

Data Collection Form for Intent Notification pursuant to Section 25(1) ZAG in conjunction with Section 7 ZAGAnzV (Agent Notification) from:

for the following institution:

Institution
BAKIS Number

1. Information on the intended agent

Please complete this section, regardless of whether the agent is a natural person, a company, or an institution. Please note the required information under "Type of Agent". If the agent is a supervised institution, please also enter the corresponding BAKIS number.

Surname
First Name¹
Address
Date of Birth²
Type of Agent	Please click/mark the applicable entry:<br>☐ Person<br>☐ Company<br>☐ Institution (BAKIS Number: _______________)
Planned Start of Activity³
Commercial Register Information	Please click/mark the applicable entry:<br>☐ HRA (Number: _______________)<br>☐ HRB (Number: _______________)<br>☐ Register Court: _______________
Tax Identification Number, VAT Identification Number (USt-IdNr.) or Economic Identification Number (W-IdNr.)
Identification Code or Reference Number

¹ Only to be completed if the agent is a natural person. ² Only to be completed if the agent is a natural person. ³ Please note that the planned start of the agent's activity specified by you may deviate from the entry in the Payment Institution Register due to the examination to be carried out. See here the Payment Institution Register at URL: https://portal.mvp.bafin.de/database/ZahlInstInfo/

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Payment services of the payment institution with which the agent is entrusted

2. Information on the managing directors of the intended agent

Please complete the following table(s) for the respective managing directors, if the agent mentioned under 1. is a company or institution:

2.1. Managing Directors of the Company (Agent)

Surname
First Name
Address
Date of Birth
Planned Start of Activity

2.2. Managing Directors of the Company (Agent)

Surname
First Name
Address
Date of Birth
Planned Start of Activity

2.3. Managing Directors of the Company (Agent)

Surname
First Name
Address
Date of Birth
Planned Start of Activity

2.4. Managing Directors of the Company (Agent)

Surname
First Name
Address
Date of Birth
Planned Start of Activity

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Note: The submission of the data collection form provided here does not exempt the institution from submitting further documents required for the intent notification pursuant to Section 25(1) ZAG in conjunction with Section 7 ZAGAnzV. Pursuant to Section 7 ZAGAnzV, the documents listed in Section 1(1) Sentence 1 Numbers 1, 2, 4, 6, 7, 9, and 10 of the Agent Notification Ordinance (AgNwV) and the agreement pursuant to Section 2(1) AgNwV must be submitted. Reference is made to Section 7(1) Sentence 2 ZAGAnzV and Section 7(2) ZAGAnzV.

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