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Subject

Complaints Area

Legal First and Last Name

Address (street, house number, zip code, city, country)

Phone number

Different contact details?(optional)

if necessary and different from personal data of the complainant

Different first and last name(optional)

Different email address(optional)

Different address (street, house number, zip code, city, country)(optional)

Different phone number(optional)

Personal data of the legal representative(optional)

if applicable, a power of attorney or other official document as evidence of the appointment of the representative

First and last name of the legal representative(optional)

Email address of the legal representative(optional)

Address (street, house number, zip code, city, country) of the legal representative(optional)

Phone number of the legal representative(optional)

Power of attorney or other official document as proof of the appointment of the representative in the attachments(optional)

Different contact details for the legal representative?(optional)

Different first and last name of the legal representative(optional)

Different email address of the legal representative(optional)

Different address (street, house number, zip code, city, country) of the legal representative(optional)

Different phone number of the legal representative(optional)

Full identification of the crypto asset service or contract 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...)

Description

Your message for us

Date(s) of the facts giving rise to the complaint

Description of the damage, loss or disadvantage suffered (if relevant)(optional)

Additional comments or relevant information (if relevant)(optional)

Attachments(optional)

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