Notification Form for Settlement Companies Under the Financial Supervision Act

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Notification Form for Settlement Companies
Articles 2:3.0a, 2:3.0f, and 2:3.0k, Financial Supervision Act (Wft)

1 Data as referred to in Article 3.0a, part a, Decision Market Access for Financial Undertakings Wft Name of the settlement company Address of the settlement company Postal address of the settlement company Email address of the settlement company Telephone number Fax number

2 Data as referred to in Article 3.0a, part b, Decision Market Access for Financial Undertakings Wft Legal form of the settlement company

3 Data as referred to in Article 3.0a, part c, Decision Market Access for Financial Undertakings Wft Statutory name of the settlement company Statutory seat of the settlement company Trade name(s) of the settlement company

4 Data as referred to in Article 3.0a, part d, Decision Market Access for Financial Undertakings Wft The registration number in the trade register of the Chamber of Commerce

De Nederlandsche Bank n.v. (DNB) will include the data provided on the basis of this form in a personal data processing operation within the meaning of the Personal Data Protection Act (Wbp). The personal data processing has been registered with the Personal Data Protection Authority. The registration form is available for inspection at DNB.

We always handle your data carefully. We may only exchange your data with third parties if legally permitted, for example with supervisors and criminal justice authorities in the Netherlands or abroad.

Any change in circumstances on the basis of which the questions below should otherwise be answered by you must be reported to DNB on your own initiative and without delay.

We request that you indicate which documents you are attaching to this form by checking the boxes next to the relevant questions.

The data provided by you will be included by DNB in the public register maintained by it as referred to in Article 1:107, first paragraph, of the Wft.

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5 Data as referred to in Article 3.0a, part e, Decision Market Access for Financial Undertakings Wft A certified copy of the statutes of the settlement company* Attached as Appendix A

6 Data as referred to in Article 3.0a, part f, Decision Market Access for Financial Undertakings Wft A statement of the activities carried out by the settlement company Attached as Appendix B

Please check which settlement services are provided (check the relevant services if multiple services are provided) a Settlement services aimed at forwarding, by a party other than a provider of communication networks, requests concerning the approval of payment orders; b Settlement services aimed at approving requests as referred to under a, on behalf of a paying payment service provider; c Netting

7 Statement of the manner in which the settlement services are provided Please check what applies By means of a settlement company with its seat in the Netherlands By means of a branch office of a settlement company with its seat in a designated state By means of a branch office of a settlement company with its seat in a non-designated state By means of providing services to the Netherlands by a settlement company with its seat in a designated state By means of providing services to the Netherlands by a settlement company with its seat in a non-designated state

8 Signature by the person(s) authorized to represent The undersigned declare(s) to have taken note of the above-mentioned statements regarding the processing of personal data in accordance with the provisions of the Wbp, the making of notifications of any changes in the answers to the questions asked, and the inclusion of provided data in the public register as referred to in Article 1:107 of the Wft.

The undersigned declare(s) to have completed this request form and the attachment(s) fully and truthfully.

Date Date
Place Place
Name Name
Position Position
Signature Signature

The fully completed and signed form, together with attachments, can be sent to:
De Nederlandsche Bank n.v., Market Access Expertise Centre, P.O. Box 98, 1000 AB Amsterdam.

For any questions, you can contact the Information Desk of De Nederlandsche Bank n.v. via telephone number 0800 020 1068 or via email (info@dnb.nl)

• If the original documents are not in Dutch or English, also submit a certified translation in one of these languages.