MALTA FINANCIAL SERVICES AUTHORITY
Authorisation Forms

Form AA116: Notification Form for the appointment of Distributors locally
High Level Guidelines
General This form, Form AA116: Notification Form for the appointment of Distributors locally (‘Notification’), shall be duly filled in by Maltese Financial Institutions wishing to appoint a distributor locally as per Article 8A of the Financial Institutions Act (Chapter 376 of the Laws of Malta) and Rule 3-2.6.6 of FIR03. In this respect, the Maltese Financial Institution (hereinafter ‘the Applicant’) shall to the best of its knowledge, provide information, which is truthful, accurate and complete. The Applicant shall notify the MFSA immediately if the information provided changes in any respect either prior to or subsequent to authorisation. The Applicant shall note that it is a criminal offence, under Article 22(1)(c) & (d) of the Act, to furnish information or to make a statement which one knows to be inaccurate, false or misleading in any material respect, or to recklessly furnish information or to make a statement which is inaccurate, false or misleading in any material respect, pursuant to any of the provisions of this Act or of any Regulations made or of any Rules issued thereunder, or any condition, obligation, requirement, directive or order made or given as aforesaid. The Applicant is required to make reference, and where applicable comply with, the Act, the Regulations made, or Rules issued thereunder during the completion of the Application. The Applicant shall also refer to the respective National and/or European Regulatory Frameworks or other binding regulation as may be applicable. The Applicant shall not tamper with, or modify in any manner, this Application or its respective Annexes. Should it transpire that the documents were tampered with, or modified in any manner, the Authority shall consider the Application to be invalid. Any potential improvements should be communicated to the MFSA for consideration. The Authority may at its sole discretion request from the Applicant further information/documentation. Definitions For the purposes of this Notification, the definitions identified below should be read in conjunction with the provisions of the Act. In the event that any of the definitions contained hereunder conflict with a definition under the Act, the definitions set out in the Act or in any other such law shall prevail, unless otherwise specified herein. ‘Act’ means the Financial Institutions Act (Chapter 376 of the Laws of Malta) ‘Authority’ means the Malta Financial Services Authority established by the Malta Financial Services Authority Act (Chapter 330 of the Laws of Malta) Instructions The Applicant is required to complete all the respective sections of the Application, as follows: Section 1 – Applicant Details Section 2 – Distributor Identification Details Section 3 –Activities of Distributor Section 4 – Internal Controls Declaration Form Applicants are to note that further instructions in relation to the Notification may be found on the Guidelines to the Authorisation Forms (link). It is noted that the Application should reflect the Applicant’s structure and method of operations at time of notification. Following submission of the Application via the LH Portal, the Declaration Form should be printed and sent, originally signed, to the Authority. In the printed Declaration Form, the Applicant is reminded to enter the Application ID, which is provided automatically through the LH Portal upon on-line submission of the Notification. It is to be noted that only this Declaration Form should be sent physically to the Authority, unless it is signed using a valid qualified signature in accordance with the circular issued by the MFSA on the use of electronic signatures dated 15 November 2022. Further instructions can be found in the Declaration Form itself. In order for the Notification to be considered complete, the Applicant is required to have submitted, along with a duly filled Application, all the required documentation as identified within this Notification. Privacy Notice The MFSA ensures that any processing of personal data is conducted in accordance with Regulation (EU) 2016/679 (General Data Protection Regulation), the Data Protection Act (Chapter 586 of the Laws of Malta) and any other relevant European Union and national law. For further details, you may refer to the MFSA Privacy Notice available on the MFSA webpage https://www.mfsa.mt/privacy-notice/. Disclaimer It is noted that the submission of this Notification and/or its determination of ‘completeness’ shall not be construed as a granting of authorisation by the MFSA.

Applicant Details
Identification Details
Authorisation ID	Enter text
LEI Code (if available)	Enter text
Registered Name	Enter text
Registered Number	Enter text
Contact Person (Note: This refers to a contact point of the Applicant)
Title	Select item
Name	Enter text	Surname	Enter text
Business Email Address	Enter text	Business Direct Number	Enter text

Distributor Identification Details
Distributor Details (Note: This sub-section may be repeated as necessary)
Distributor Type	Select item
Distributor Identification Details (Note: This is only applicable in case of ‘Legal Person’)
General Details
Name of Distributor	Enter text
Company Registration Number or equivalent	Enter text
Business Email Address	Enter text
Business Direct Number	Enter text
Registered Address
Number/Name	Enter text	Street/Road	Enter text
City/Town/Village	Enter text	Region/State	Enter text
Post Code	Enter text	Country	Enter text
Legal Representative
Title	Select item
Name	Enter text	Surname	Enter text
Date of Birth	Enter date	Place of Birth	Enter text
(Add more as applicable)

Distributor Identification Details
Distributor Identification Details (Note: This is only applicable in case of ‘Natural Person’)
General Details
Title	Select item
Name	Enter text	Surname	Enter text
Date of Birth	Enter date	Place of Birth	Enter text
ID Type	Select item	ID Number	Enter text
ID Expiry Date	Enter date	Country of Issuance	Select country
Business Email Address	Enter text	Business Direct Number	Enter text
Address
Number/Name	Enter text	Street/Road	Enter text
City/Town/Village	Enter text	Region/State	Enter text
Post Code	Enter text	Country	Enter text
(Add more as applicable)

Section 3 – Activities of Distributor
Proposed Activity
Proposed date of commencement of activities/services	Enter date
Electronic money services to be provided by the Distributor
Activities
Distribution of electronic money	Select item
Redemption of electronic money	Select item

Section 4 – Internal Controls
Internal Controls
Provide a description of the internal control mechanisms that will be used by the Applicant/Distributor in order to comply with the obligations in relation to AML/CFT requirements
Enter text
Attachment | Policies and Procedures
Outsourcing of Operational Functions (if applicable)
Indicate whether the operational functions of the Applicant shall be outsourced. If in the affirmative, explain the type of operational functions of the e-money services that shall be outsourced and provide an exhaustive description thereof.	Enter text
Details of the Outsourcing Company
Name of Outsourcing Service Provider	Enter text
Address of Outsourcing Service Provider
Number/Name	Enter text	Street/Road	Enter text
City/Town/Village	Enter text	Region/ State	Enter text
Post Code	Enter text	Country	Enter text
Contact Details of a person within the Outsourcing Service Provider
Title	Select item
Name	Enter text	Surname	Enter text
Business Email Address	Enter text	Business Direct Number	Enter text
Attachment | Outsourcing Contractual Agreements

Declaration Form
Following submission of the Application, this Declaration Form should be printed and sent, originally signed, to the attention of Authorisations, Fintech Supervision Function, MFSA. It is to be noted that only this form should be sent physically to the Authority and that should the Applicant submit the entire Application, only the version submitted via the LH Portal shall be maintained and used for the purposes of the MFSA’s authorisation processes. Where the Applicant is a natural person, this Declaration Form is to be signed by the individual. On the other hand, where the Applicant is a not a natural person, this Declaration Form should be signed by the two signatories vested with legal representation of the Applicant.
The undersigned, on behalf of Applicant, declare that: Notification Submission and Authorisation Requirements the Applicant has resolved to submit this notification with the MFSA for the activities provided for within this Application; the Applicant has duly authorised the undersigned to complete and submit this Notification to the MFSA; the Applicant is aware of the requirements under the provisions of the Act; and the Applicant shall at time of authorisation, should this be granted, be in adherence with the obligations stipulated under point 1 (c) above. Information Provided to Authority the information given in answer to the questions within the Notification is complete and accurate to the best of our knowledge, information and belief and that there are no other facts relevant to this Notification of which the Authority should be aware; the Applicant has not tampered with, or modified in any manner, this Notification or its respective Annexes, and understands that such tampering with, or modification in any manner of these documents will result in a refusal of this Notification; there are no inconsistencies between the provisions of the Constitutional Documents, the documents submitted with this Notification (where applicable) and the information given in answer to the questions within the Notification; the MFSA will be notified immediately if the information given in answer to the questions within the Notification changes and/or affects the completeness or accuracy the Notification either prior to or subsequent to authorisation should this be granted; and this Declaration Form corresponds to the Notification submitted to the Authority via the LH Portal bearing the following ID: Application ID This ID is provided automatically by the MFSA through the LH Portal and is not required for the on-line submission of the Application. In this respect, following submission of this Application via the LH Portal the Application ID will be available on the submission page and also within the acknowledgement email. Enter text
the following documentation as indicated in the below have been submitted together with this Application: Checklist of Documentation to be Submitted with the Application Policies and Procedures Enter number of submissions Outsourcing Contractual Agreements (if applicable) Enter number of submissions Any other document/s (if applicable) Enter number of submissions
Representatives and Disclosure the MFSA is hereby being authorised to make such enquiries as it may consider necessary in connection with this Notification; and the MFSA is hereby being authorised to contact any or all of the above-named or any other person considered by the Authority to be relevant, both at the date of notification and at any time in the future unless and until I/we rescind this authority in writing. Privacy Notice I/we have read and understood the MFSA Privacy Notice and the terms and conditions included therein.
Signature 1
Name	Enter text	Surname	Enter text
Position	Enter text
Date	Enter date
Signature 2
Name	Enter text	Surname	Enter text
Position	Enter text
Date	Enter date

For further information visit: https://www.mfsa.mt/privacy-notice/