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PSD Standard Notification Form

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					                                                                                                            Standard Notification

Application for Authorised Payment Institution
Qualifying holding (Controller)
Standard Notification

  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
  those purposes.
  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
            question; and

           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
      this application.
                              Version 1.0 – April 2009                                                                    page 1
  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.
                                                                            Standard Notification




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?
       NoContinue 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




    Version 1.0 – April 2009                                                              page 2
                                                                                     Standard Notification




    EEA information
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
            2006); and

       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”

        NoContinue to question 1.7
        YesGive details below


        Name of controller


        Country the controller is authorised in


        Regulator's name


        Regulator's telephone number


        Description of business controller carries on




     Version 1.0 – April 2009                                                                       page 3
                                                                                 Standard Notification




1.7      Is the controller detailed in question 1.1 a regulated financial services provider
         regulated by a body other than the FSA?
            NoContinue to section 2
            YesGive details below
         Regulator's name


         An identifying number allocated to the controller by the regulator


         A contact name, if known, at the regulator


         Regulator's address




      Version 1.0 – April 2009                                                                page 4
                                                                                    Standard Notification




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

                                     dd/mm/yy

                                     dd/mm/yy

                                     dd/mm/yy

                                     dd/mm/yy

                                     dd/mm/yy

                                     dd/mm/yy

                                     dd/mm/yy

                                     dd/mm/yy




        Version 1.0 – April 2009                                                                 page 5
                                                                                   Standard Notification




3 Declaration
  Who must sign the declaration?
   Type of applicant                                Who must sign
   A sole trader who employs one or more            The sole trader
   approved persons

   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
  incomplete.

  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
  above.

   Name

   Position

   Signature



   Date            dd/mm/yy



  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.


   Version 1.0 – April 2009                                                                     page 6

				
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