1 Personal identification details Financial Services Auth Remove a psd individual

1 Personal identification details

Financial Services Auth


Remove a PSD Individual

Payment Services Regulations 2017

Name of the Payment Institution (as entered in Question 1.1)

     

Firm reference number (FRN) (as entered in Question 1.2)

     

Important information you should read before completing this form

This form should be completed and submitted by the Payment Institution (PI) making the notification on behalf of the PSD Individual to whom the removal relates to. This form needs to be signed by the PI making this notification.

Please keep a copy of the forms you complete and any supporting documents you include with this application for your future reference.

The FCA processes personal data in line with the requirements of The General Data Protection Regulation (EU) 2016/679 and the Data Protection Act 2018. For further information about the way we use the personal data collected in this form, please read our privacy notice available on our website: www.fca.org.uk/privacy .

It is important that you provide accurate and complete information, and disclose all relevant information. If you do not, you may be committing a criminal offence and it may increase the time taken to assess your application.
Contents of this form

1	Personal identification details	3
2	Information on PSD individual(s) to be removed	4
3	Supplementary information	6
4	Declaration and signature	7

Application for Authorisation as a

Payment Institution
Financial Services Authority

Application for Authorisation as a

Payment Institution
Filling in the form

1 If you are using your computer to complete the form use the TAB key to move from question to question and press SHIFT TAB to move back to the previous question.

2 If you are filling in the form by hand:

• 
  use black ink
  
• 
  write clearly
  

3 If you think a question is not relevant to you, write 'not applicable' and explain why.

4 If you leave a question blank without telling us why, we will have to treat the application as incomplete. This will increase the time taken to assess your application.

5 If there is not enough space on the forms, you may need to use separate sheets of paper. Clearly mark each separate sheet of paper with the relevant question number.

6 The completed form should be emailed as a scanned (PDF) copy to:
[e-mail]

1.8 Previous name

     

1.9 Date of name change (dd/mm/yyyy)

     

     

/

     

     

/

     

     

     

     

1.10a Nationality

     

1.10b Passport number

     

1.11 Place of birth

     

1.12 Private address

Business address	     
Postcode	     

1.9 Dates resident at this address (mm/yyyy)

     

     

/

     

     

     

     

To Present

If address has changed in the last three years, please provide addresses for the previous three years.

1	Personal identification details

1.1 Name of the small or authorised Payment Institution

     

1.2 FCA Firm Reference Number (FRN)

     

1.3 Who should the FCA contact at the applicant firm in relation to this application?

Name

     

Position

     

Telephone

     

Fax

     

Email

     

2	Information on PSD individual(s) to be removed

2.1 Please indicate the total number of PSD individual(s) to be removed

     

2.2 Please list the PSD Individual(s) that will no longer be responsible for the management of the Payment Institution, and/or its payment services, together with an effective date and a reason.

Individual 1

Full name of individual

     

Individual Reference (IRN)

     

Cessation date (dd/mm/yyyy)

     

     

/

     

     

/

     

     

     

     

Reason (please provide a full explanation in 3.1)

  Internal movement of staff

  Resignation

  Redundancy

  Retirement

  End of contract

  Dismissal/termination of employment or contract (specify in 3.1)

  Suspension (specify in 3.1)

  Other (specify in 3.1)

Individual 2

Full name of individual

     

Individual Reference (IRN)

     

Cessation date (dd/mm/yyyy)

     

     

/

     

     

/

     

     

     

     

Reason (please provide a full explanation in 3.1)

  Internal movement of staff

  Resignation

  Redundancy

  Retirement

  End of contract

  Dismissal/termination of employment or contract (specify in 3.1)

  Suspension (specify in 3.1)

  Other (specify in 3.1)

Individual 3

Full name of individual

     

Individual Reference (IRN)

     

Cessation date (dd/mm/yyyy)

     

     

/

     

     

/

     

     

     

     

Reason (please provide a full explanation in 3.1)

  Internal movement of staff

  Resignation

  Redundancy

  Retirement

  End of contract

  Dismissal/termination of employment or contract (specify in 3.1)

  Suspension (specify in 3.1)

  Other (specify in 3.1)

I have supplied further information related to this page in
Section 3

  No   Yes

3	Supplementary information

3.1 Please indicate clearly which question the supplementary information relates to.

Question	Information
     	     

Please indicate how many additional sheets are being submitted

     

4	Declaration and signature

Declaration of Payment Institution

The notification must be signed by PSD Individual(s) who have the appropriate responsibility for submitting the notice on behalf of the Payment Institution. The appropriate person(s) depends on the Payment Institution’s firm type. See Chapter 3 of the Approach Document.

It is a criminal offence (under Regulation 114) to knowingly or recklessly give us information which is false or misleading in a material particular. If necessary, appropriate professional advice should be sought before supplying information to us.

There may be a delay in processing the notification if any information is inaccurate or incomplete.

You must notify us immediately of any material change to the information provided (see Regulation 16). Failure to notify us immediately of any significant change to the information provided may result in a delay in the notification process

All information that the FCA might reasonably consider relevant to this notification should be supplied to the FCA. It should not be assumed that information is known to the FCA merely because it is in the public domain or has previously been disclosed to the FCA or another regulatory body, and the Payment Institution making this notification is not entitled to assume that, in assessing this notification, the FCA will check its existing records in respect of (or for information relating to) the Payment Institutions or persons connected to it. If there is any doubt about the relevance of information, it should be included.

In signing the declaration below to I confirm that:

• 
  I am authorised to make this notification to remove the PSD individual(s) noted in section 2 on behalf of the Payment Institution named on the front of this form.
  
• 
  I understand it is a criminal offence to knowingly or recklessly give the FCA information that is materially false, misleading or deceptive.
  
• 
  The information in this notification is accurate and complete to the best of my knowledge and belief, and I have taken all reasonable steps to ensure that the information in this notification is accurate and complete.
  
• 
  I authorise the FCA to make such enquiries and seek such further information as it thinks appropriate in the course of verifying the information given in this form, including (if appropriate) requesting further information or documents from the Payment Institution submitting this notification and/or making relevant enquiries with third parties.
  
• 
  I consent to receive communications from the FCA via post or email.
  

Name of signatory (this must be someone authorised to sign this form on the Payment Institution’s behalf)

     

Position in the Payment Institution

     

Individual Reference Number (IRN) of signatory

     

Signature

Date (dd/mm/yyyy)

     

     

/

     

     

/

     

     

     

     

FCA  Remove PSD Individual  Release 5  May 2018 page