Application for Authorised Payment Institution
Qualifying holding (Controller)
Full name of applicant firm
Form for controllers of a firm applying for authorisation; only to be used if you are:
a person responsible for Payment Services;
an FSA Authorised Payment Institution;
an FSA Registered Small Payment Institution;
an FSA Approved Person;
an FSA authorised firm; or
an existing Controller of an FSA authorised firm.
Important information you should read before completing this form
For the purposes of complying with the Data Protection Act 1998, please note that any personal
information provided to us will be used to discharge our statutory functions under The Payment
Services Regulations 2009 and other relevant legislation and may be disclosed to third parties for
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, it may increase the time
taken to assess your application.
Terms in this form
In this form the FSA uses the following terms:
‘FSA', ‘we’, 'our', or ‘us’ refers to the Financial Services Authority;
‘Applicant firm’ refers to the firm applying for authorisation;
‘Controller’ means a person with a qualifying holding;
‘You’ refers to the person(s) signing the form on behalf of the controller; and
‘Regulations’ refers to The Payment Services Regulations 2009.
Purpose of this form
This form collects information about the controller of the applicant firm.
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
print out the completed form and sign the declaration in section 3.
2 If you are filling in the form by hand:
use black ink;
write clearly; and
sign the declaration in section 3.
3 If you leave a question blank or do not sign the declaration or do not attach the required supporting information and
do not tell us why, we will have to treat the application as incomplete, which will increase the time taken to assess
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4 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.
1 Controller’s details
1.1 Name of controller
1.2 You must list the names of the applicant firm(s)
1.3 Are you already an FSA person responsible for payment services, an FSA
Authorised or Registered small payment institution, an FSA approved person or
FSA authorised firm?
No Continue to question 1.4
Yes You must give your FSA reference number below
1.4 Are you a controller of any other FSA-authorised or registered firms?
NoContinue to question 1.5
Yes You must detail the name(s) and FSA reference number of each firm.
Name of firm(s) FSA reference number
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1.5 Are you an individual?
Yes Continue to Section 3
No Continue to question 1.6
1.6 Do all of the following statements apply:
i.The qualifying holding is held by an “EEA authorised payment institution” as
defined in 2(1) of the Regulations or “EEA firm” as defined in paragraph 5 of
Schedule 3 to the Financial Services and Markets Act 2000);
ii. The applicant firm is connected with the qualifying holding because it is a
subsidiary undertaking of the qualifying holding or a subsidiary undertaking of a
parent undertaking of the qualifying holding ("subsidiary undertaking" and "parent
undertaking" have the meaning given by Section 1162 of the Companies Act
iii. The qualifying holding is as defined in the Regulations by reference to Article 4(11)
of the Banking Consolidation Directive (BCD). The definition in the BCD is a “direct
or indirect holding in an undertaking which represents 10% or more of the capital or
the voting rights or which makes it possible to exercise a significant influence over
the management of the undertaking”
NoContinue to question 1.7
YesGive details below
Name of controller
Country the controller is authorised in
Regulator's telephone number
Description of business controller carries on
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1.7 Is the controller detailed in question 1.1 a regulated financial services provider
regulated by a body other than the FSA?
NoContinue to section 2
YesGive details below
An identifying number allocated to the controller by the regulator
A contact name, if known, at the regulator
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2 About the directors/partners/members of the controller
2.1 You must give details of the controller’s directors, partners or members.
Full name Date of birth Position
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Who must sign the declaration?
Type of applicant Who must sign
A sole trader who employs one or more The sole trader
A company with one or more directors One director
A partnership One partner
A limited partnership A general partner
A limited liability partnership One member
A trust Trustee
It is a criminal offence knowingly or recklessly to give us information that is materially
false, misleading or deceptive. If necessary, appropriate professional advice should be
sought before supplying information to us.
There will be a delay in processing the application if any information is inaccurate or
Failure to notify us immediately of any significant change to the information provided may
seriously delay the application process.
I understand it is a criminal offence knowingly or recklessly to give the FSA information
that is materially false, misleading or deceptive.
I confirm that the information in this form is accurate and complete to the best of my
knowledge and belief.
I authorise the FSA to make such enquiries and to seek such further information as it
thinks appropriate to verify the information given on this form. I also understand that
the results of these checks may be disclosed to the applicant for authorisation.
I confirm that I am authorised to sign on behalf of the controller named in question 1.1
What to do next
You must give this form back to the person who is responsible for making the application
for an authorised payment institution. They should send the form back to the FSA.
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