Suspicious Transaction and Order Report (STOR) Form

Suspicious Transaction and Order Report (STOR) [This form is for notification of suspicious orders and transactions under Article 92 of Regulation (EU) 2023/1114 of the European Parliament and of the Council of 31 May 2023 on market abuse (Market in Crypto Asset Regulation)] Please note that all fields in Sections 1-4 are mandatory. Where information cannot be provided for a specific field, please indicate ‘NA’ and briefly explain the reasons thereof.
SECTION 1 – IDENTITY OF ENTITY/PERSON SUBMITTING the STOR
Persons professionally arranging or executing transactions in crypto assets – Specify in each case:
Name of the natural person
Position within the reporting entity
Name of the reporting entity
Address of the reporting entity
Acting capacity of entity with respect to the orders, transactions or behaviours related to the functioning of the DLT that could constitute market abuse Type of trading activity (market making, arbitrage etc.) and type of crypto-asset traded by the reporting entity Contact for additional request for information Have the facts already been reported to public authorities?
SECTION 2 - TRANSACTION/ORDER/BEHAVIOUR AND OTHER ASPECTS RELATED TO THE FUNCTIONING OF THE DISTRIBUTED LEDGER TECHNOLOGY
Description of the crypto-asset
Name(s) of the distributed ledger(s)
Trading platform where order was placed or the transaction was executed Location (country) Description of the order, transaction or suspicious behaviour related to the functioning of the DLT
SECTION 3 - DESCRIPTION OF THE NATURE OF THE SUSPICION
Nature of the suspicion
Reasons for the suspicion
SECTION 4 - IDENTIFICATION OF PERSON(S) RESPONSIBLE FOR THE ORDERS, TRANSACTIONS OR BEHAVIOUR RELATED TO THE FUNCTIONING OF THE DISTRIBUTED LEDGER TECHNOLOGY THAT COULD CONSTITUTE MARKET ABUSE (‘SUSPECTED PERSON’)
Name
National Identification Number
Address
Information about the employment:
– Place
– Position
Account number(s) and wallet address(es
Client identifier
Relationship with the issuer of the crypto asset concerned
SECTION 5 - ADDITIONAL INFORMATION
Other information relevant to the report, depending on the activity
SECTION 6 - DOCUMENTATION ATTACHED