Please note that all fields in Sections 1-4 are mandatory. Where information cannot be provided for a specific field, please indicate ‘NA’ and briefly explain the reasons thereof.

SECTION 1 – IDENTITY OF ENTITY/PERSON SUBMITTING THE STOR

Persons professionally arranging or executing transactions in crypto assets – Specify in each case:

Name of the natural person

[First name(s) and surname(s) of the natural person in charge of the submission of the STOR within the submitting entity.]

Position within the reporting entity

[Position of the natural person in charge of the submission of the STOR within the submitting entity.]

Name of the reporting entity

[Full name of the reporting entity, including for legal persons:

Address of the reporting entity

[Full address (e.g. street, street number, postal code, city, state/province) and country.]

Acting capacity of entity with respect to the orders, transactions or behaviours related to the functioning of the DLT that could constitute market abuse

[Description of the capacity in which the reporting entity was acting with regards to the order(s), transaction(s) or behaviour(s) related to the functioning of the distributed ledger technology that could indicate the existence of market abuse, e.g. executing orders on behalf of clients, operating a trading platform ...]

Type of trading activity (market making, arbitrage etc.) and type of crypto-asset traded by the reporting entity

[Description of any corporate, contractual or organisational arrangements or circumstances or relationships.]

Contact for additional request for information

[Person to be contacted within the reporting entity for additional request for information relating to this report (e.g. compliance officer) and relevant contact details, if not the same as person in charge of the submitting of the STOR:

Have the facts already been reported to public authorities?

Please state whether the facts have already been reported to public authority (and in that case indicate the name of the authority).

SECTION 2 – TRANSACTION/ORDER/BEHAVIOUR AND OTHER ASPECTS RELATED TO THE FUNCTIONING OF THE DISTRIBUTED LEDGER TECHNOLOGY

Description of the crypto-asset:

Describe the crypto-asset(s) which is the subject of the STOR, specifying:

Name(s) of the distributed ledger(s):

[Provide the full name(s) of the distributed ledger(s) where the suspicious behaviour was observed]

Trading platform where order was placed or the transaction was executed

[Specify name and Market Identifier Code (MIC) in accordance with ISO 10383 to identify the trading platform where the order was placed or the transaction was executed.

Where the order/transaction was not identified in a trading platform, please mention ‘outside a trading platform’ and the LEI of the crypto-asset service provider that carried out the transaction where applicable.]

Location (country)

[Full name of the country and the ISO 3166-1 two-character country code.]

[Specify where:

Description of the order, transaction or suspicious behaviour related to the functioning of the DLT

[Describe at least the following characteristics of the order(s) transaction(s) or behaviour(s) reported:

[Where there are multiple orders or transactions that could constitute market abuse the details on the prices and volumes of such orders and transactions can be provided to the competent authority in an Annex to the STOR.]

In case of reporting a suspicious behaviour related to the functioning of the distributed ledger, please provide as much detail as possible, including the impact it had on the validation of transactions and the method used to alter the functioning of the DLT.

SECTION 3 – DESCRIPTION OF THE NATURE OF THE SUSPICION

Nature of the suspicion

[Specify the type of breach based on which the reported order(s), transaction(s), behaviour(s) related to the functioning of the DLT, could constitute market abuse].

Reasons for the suspicion

[Description of the activity (transactions and orders, way of placing the orders or executing the transaction and characteristics of the orders and transactions that make them suspicious, behaviours related to the functioning of the DLT) and how the matter came to the attention of the reporting person and specify the reasons for suspicion.

For crypto-assets admitted to trading on/traded on a trading platform, a description of the nature of the order book interaction/transactions that could constitute market abuse.]

SECTION 4 – IDENTIFICATION OF PERSON(S) RESPONSIBLE FOR THE ORDERS, TRANSACTIONS OR BEHAVIOUR RELATED TO THE FUNCTIONING OF THE DISTRIBUTED LEDGER TECHNOLOGY THAT COULD CONSTITUTE MARKET ABUSE (‘SUSPECTED PERSON’)

Name

[For natural persons: the first name(s) and the last name(s).]

[For legal persons: full name including legal form as provided for in the register of the country pursuant to the laws of which it is incorporated, where applicable, and Legal Entity Identifier (LEI) code in accordance with ISO 17442.]

National Identification Number

[Number and/or text].

[Where the National Identification Number is not applicable or known, provide a date of birth (for natural persons only) in the ISO 8601 format]

Address

[Full address (e.g. street, street number, postal code, city, state/province) and country.]

Information about the employment: – Place – Position

[Information about the employment of the suspected person, from information sources available internally to the reporting entity (e.g. account documentation in case of clients, staff information system in case of an employee of the reporting entity).]

Account number(s) and wallet address(es)

[Numbers of the cash account(s), any joint accounts or any Powers of Attorney on the account the suspected entity/person holds.

Wallet address(es) involved in the transaction or suspected behaviour]

Client identifier

[In case the suspected person is a client of the reporting entity.]

Relationship with the issuer of the crypto-asset concerned

[Description of any corporate, contractual or organisational arrangements or circumstances or relationships]

SECTION 5 – ADDITIONAL INFORMATION

Other information relevant to the report, depending on the activity

[The following list is indicative and not exhaustive. Other information deemed useful by the reporting person may be provided where relevant to the STOR.]

SECTION 6 – DOCUMENTATION ATTACHED

[List the supporting attachments and material together provided with this STOR].

[Examples of such documentation are e-mails, recordings of conversations, order/transaction records, distributed ledger technology records, confirmations, broker reports, Powers of Attorney documents, and comment by media where relevant.

Where the detailed information about the orders/transactions/behaviours related to the functioning of the distributed ledger technology referred to in Section 2 is provided in a separate annex, indicate the title of that annex.]