Action to date

Yes, I have previously lodged or registered this dispute with the Financial CommissionNo, this is the first time I have lodged or registered this dispute with the Crypto Conduct Authority

Applicant Details

Dispute Details

Name of the financial services provider you have a dispute with

Please provide a reference number so that your financial services provider can locate the correct information

Please describe the nature of your complaint.

Please include as much information as you can, including the type of product involved, the dates the problem occurred,
the name, address and telephone number (if you know these) of all individuals and firms involved and a description
of the problem (please attach a separate page if you need more space than provided)

Additional COmments

What do you think is a fair and reasonable resolution to the dispute?

If you are seeking payment of a sum of money please provide any relevant calculations of your claim(s)

Information you don't have to submit:

• Any personal identifiers (ID, driver’s license, passports, etc);

• Financial documents including bank account statements and credit card information;

• Personal account information: login, password, email address.