CLAIM FORM
1. SUBMISSION OF A CLAIM
(to be sent by the customer to Relai)
1.a Personal Data of the claimant
| LAST NAME / LEGAL ENTITY NAME | FIRST NAME | REGISTRATION or ID NUMBER | LEI (IF AVAILABLE) | CLIENT REFERENCE (IF AVAILABLE) |
| ADDRESS: STREET, NUMBER, FLOOR (for firms registered office) | POSTCODE | CITY | COUNTRY |
| PHONE | |||
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 |
| PHONE |
2. Legal representative
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 / LEGAL ENTITY NAME | FIRST NAME |
| ADDRESS: STREET, NUMBER, FLOOR (for firms registered office) | POSTCODE | CITY | COUNTRY |
| PHONE |
3. INFORMATION ABOUT THE CLAIM
3.a Full reference of the crypto-asset service or agreement to which the complaint relates (i.e. name of the crypto-asset service provider, crypto-asset service reference number, or other references of the relevant transactions…)
3.b Description of the complaint’s subject-matter
Please provide documentation supporting the facts mentioned.
3.c Date(s) of the facts that have led to the complaint
3.d Description of damage, loss or detriment caused (where relevant)
3.e Other comments or relevant information (where relevant)
In _________________
Signature:
Please attach any supporting documents referenced above.