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
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Personal identification details
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3
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2
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Information on PSD individual(s) to be removed
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4
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3
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Supplementary information
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6
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4
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Declaration and signature
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7
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3
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Supplementary information
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3.1 Please indicate clearly which question the supplementary information relates to.
Please indicate how many additional sheets are being submitted
4
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Declaration and signature
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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:
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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.
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I understand it is a criminal offence to knowingly or recklessly give the FCA information that is materially false, misleading or deceptive.
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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.
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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.
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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
Date (dd/mm/yyyy)