MSB Notification Form for De Minimis Turnover Exemption

May 2018 Financial Services Act 2008 Notification of Provision of Money Transmission Services Please return this form to: Isle of Man Financial Services Authority PO Box 58 Finch Hill House Bucks Road Douglas Isle of Man IM99 1DT

Isle of Man Financial Services Authority May 2018 Page 2 of 6 Notes The Financial Services Act 2008 requires those undertaking money transmission services in or from the Island to be licensed by the Isle of Man Financial Services Authority (“the Authority”). However, under the Financial Services (Exemptions) Regulations 2011, a business with a turnover of less than £50,000 during the previous 12 calendar months, and which continues to have an annual turnover below £50,000, does not need to be licensed, provided it has notified the Authority that it is undertaking money transmission services. This notification form is to be completed by any business which intends to take advantage of the exemption from licensing due to having an annual turnover below £50,000. Any business intending to commence money transmission services must notify the Authority before doing so. It is recommended that anyone completing this form should read and make themselves familiar with paragraph and 8.1 of the Financial Services (Exemptions) Regulations 2011. Please complete all sections of the form. Where something is not applicable please write “N/A” beside the question. The form can be downloaded from our website in Microsoft Word format, with boxes that will expand to fit the text. Alternatively, the applicant can print the form and complete it in black ink.

Isle of Man Financial Services Authority May 2018 Page 3 of 6 Section 1: About the Business

1. Full name of business
2. Trading name (if different from above)
3. Registered office address (if applicable)
4. Primary business address in the Isle of Man (if different from above)
5. Country of incorporation (if not incorporated please indicate the legal structure / status of the business)
6. Company registration number
7. Date of incorporation
8. Contact name
9. E-mail address
10. Website
11. Telephone number
12. Fax number

Isle of Man Financial Services Authority May 2018 Page 4 of 6 13. Does the business comply with the Anti-Money Laundering and Countering the Financing of Terrorism Code 2015? Yes No If no, provide details below

Isle of Man Financial Services Authority May 2018 Page 5 of 6 Section 2: Money Transmission Services

1. Indicate which of the activities the business will undertake. Operation of a bureau de change Transmission of money as principal Transmission of money as agent Provision of cheque cashing services Issuance of electronic money
2. On what date did the business commence money transmission services? For new businesses, indicate the anticipated date.
3. What was the business’ turnover, from money service activities, for the past 12 months? For new businesses, indicate the anticipated annual turnover.
4. Does the business intend to offer the services from multiple premises? Yes No If “yes”, list the addresses of all the premises below.

Isle of Man Financial Services Authority May 2018 Page 6 of 6 Section 3: Declaration I declare that the information supplied in the attached form is complete and correct to the best of my knowledge and belief at the time of this Declaration. 🔒 Data Protection Notice The Authority is registered with the Information Commissioner as a data controller under Isle of Man data protection legislation. The Authority collects and processes personal data to carry out its functions under relevant legislation and may share personal data with other parties where there is a legal basis for doing so. Information on how the Authority collects and processes personal data can be found in the Privacy Policy on the Authority’s website: https://www.iomfsa.im/terms-conditions/privacy-policy/ Please call +44 (0)1624 646000 if you have any queries. Signed (Director, or if alternative role please indicate) Name Date