Cross-Border Passporting Form

Notice of intention to provide cross-border services in another EEA state in accordance with the Payment Services Directive (PSD)

Firm Reference number (e.g. 123456):

Firm name:

HMRC Registration number:

Passporting PSD Freedom of services  Release 1  April 2013page 1

1.1 Details of the person we will contact about this notification.

2.1Please indicate the EEA State(s) into whichthe API intends provide payment services.

2.2If the API intends to provideservices in more than one EEA State, will these services vary for each State?

No

Yesplease refer to question 3.1 and complete per EEA state.

2.3 Does the payment money institution intend to engage aUK located agent to provide payment services on a freedom of services basis?

No

Yesif yes, please provide us with the firm reference number (FRN), name and address of the agent; and the kind of payment services the agent intends to provide in the host Member State on behalf of the payment institution.

(The agent(s) should be separately registered by using the ‘Add a PSD agent form’ located on our website at:

If you are using agents located in another EEA member state please disregard this form and complete the “Notice of intention to exercise the right of establishment in another EEA member state”

Please continue on a separate spreadsheet if necessary.

Please give the proposed date the services are to be provided(dd/mm/yyyy)

This cannot be less than 30 days from date we receive a complete notification.

3.1Please tick the appropriate boxes to show which payment services activitiesare to be provided by the branch

1. Services enabling cash to be placed on a payment account, as well as all the operations required for operating a payment account.

2. Services enabling cash withdrawals from a payment, as well as all the operations required for operating a payment account.

3. Execution of payment transactions, including transfers of funds on a payment account with the user’s payment service provider or with another payment service provider:

• execution of direct debits, including one-off direct debits
• execution of payment transactions through a payment card or a similar device
• execution of credit transfers, including standing orders

4. Execution of payment transactions where the funds are covered by a credit line for a payment service user:

• execution of direct debits, including one-off direct debits
  - does this include the granting of credits?
  Yes
  No

• execution of payment transactions through a payment card or a similar device
• execution of credit transfers, including standing orders

5. Issuing and/or acquiring of payment instruments:

- does this include the granting of credits?

Yes
No

6. Money remittance.

7.Execution of payment transactions where the consent of the payer to execute a payment transaction is given by means of any telecommunication, digital or IT device and the payment is made to the telecommunication, IT system or network operator, acting only as an intermediary between the payment service user and the supplier of the goods and services:

- does this include the granting of credits?

Yes

No

It is a criminal offence to knowingly or recklessly give us information that is false or misleading. If necessary, please take appropriate professional advice before supplying information to us.

There will be a delay in processing the notificationif any information is inaccurate or incomplete. Failure to notify us immediately of any significant change to the information provided may result in a serious delay in the notification process.

I understand it is a criminal offence to knowingly or recklessly give the FCA/PRAinformation that is false or misleading.

I confirm that the information in this form is accurate and complete to the best of my knowledge and belief.

I confirmthat I am authorised to sign on behalf of the authorised payment institution.

Data protection

For the purposes of complying with the Data Protection Act 1998, the personal information in this form will be used by the FCA/PRA to discharge their statutory functions under the Payment Services Regulations and other relevant legislation, and may be disclosed to third parties for those purposes.

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