Application for Authorised Payment Institution
Qualifying holding (Controller)
Full name of applicant firm
Important information you should read before completing this form
For the purposes of complying with the Data Prot ection Act 1998, please not e 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 purpos es.
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 asse ss 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 ke y to move from question to question and press SHIFT TAB to move back to the previous
print out the completed form and s ign 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
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.
Version 1.0 – April 2009 page 1
1 Trust controller’s details
1.1 Name of trust controller
1.2 Is the trustee(s) a limited company or an individual?
Limited companyYou must provide the company name, registration numbers,
registered office address and the names of the chief executive officer and directors.
IndividualYou must provide the name(s) of the trustee and a date of birth.
1.3 What is the purpose of the trust?
1.4 Do the beneficiaries have any control over the administration of the trust?
No Continue to question 1.5
Yes You must provide the beneficiaries ' full names and dates of birth
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1.5 You must provide the identity of the settlor.
If the settlor is an individual, please provide their name and date of birth.
1.6 You must give details of the source of the funds under the trustee's control.
1.7 Are the trustees aware of all beneficiaries of the trust?
No You must detail the reasons why (for example, if the selection of beneficiaries
is at the discretion of the trustees you must describe the extent of this discretion and the
type of people who may be selected as beneficiaries).
Yes You must provide details of all beneficiaries
1.8 Who has the power to appoint and remove trustees?
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1.9 You must provide the name(s) of the person(s) authorised to sign on behalf of the
1.10 You must give details of any limitations on the trustee's power of investment.
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2 About the trust controller’s structure
2.1 You must send a complete structure chart of the trust controller that shows the
percentages of holdings;
any undertaking(s ) or shares in another firm other than the applicant firm; and
any firms or individuals that are deemed to be a controller of the applicant firm by virtue
of their significant influence (see Regulation 6(6) of the Regulations).
Structure chart attached
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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 an y significant change to the information provided may
result in a serious delay in 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 trust controller named in question
1.1 above (as per 1.9).
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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