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Bequant Pro Limited · Company No. C 88065 · Malta

Complaints Form

CDR (EU) 2025/294 · Annex TemplateEffective: 08 April 2026
TEMPLATE FOR THE FILING OF COMPLAINTS — Commission Delegated Regulation (EU) 2025/294. This form is to be sent by the client to the crypto-asset service provider. To submit a completed complaint, please email compliance@bequant.io or post to FAO: Head of Compliance, Bequant Pro Limited, THE CORE, VALLEY ROAD, MSIDA, MSD 9021, Malta.

English Version — Filing of a Complaint

1.a. Information about the complainant
Last name / Legal entity name:
First name:
EUID or if not available national Registration or ID number:
Legal Entity Identifier (if available):
Client reference (if available):
Address (street, number, floor) (for legal entities, registered office):
Postcode:
City:
Country:
Telephone:
Email address:
1.b. Contact details (if different from 1.a)
Last name / Legal entity name:
First name:
Address (street, number, floor) (for legal entities, registered office):
Postcode:
City:
Country:
Telephone:
Email address:
2.a. Information about the legal representative (if applicable)
Last name / Legal entity name:
First name:
Registration number and LEI (if available):
Address (street, number, floor) (for legal entities, registered office):
Postcode:
City:
Country:
Telephone:
Email address:

A power of attorney or other official document as proof of the appointment of the representative to be provided as an attachment to this form.

2.b. Contact details (if different from 2.a)
Last name / Legal entity name:
First name:
Address (street, number, floor) (for legal entities, registered office):
Postcode:
City:
Country:
Telephone:
Email:
3. Information about the complaint
3.a. Full reference of the crypto-asset service to which the complaint relates

i.e. name of the crypto-asset service provider, crypto-asset service reference number, or other references of the relevant transactions

3.b. Description of the complaint's subject-matter

Please provide any documentation supporting the facts mentioned.

3.c. Date(s) of the facts that have led to the complaint
3.d. Description of damage, loss or detriment caused (where relevant)
3.e. Other comments or relevant information (where relevant)

In ______________________________ (place) on __________________ (date)

SIGNATURE

COMPLAINANT / LEGAL REPRESENTATIVE OF THE COMPLAINANT

Documentation provided (please check the appropriate box):
Power of attorney or other official document as proof of the appointment of the representative
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Copy of the contractual documents of the investments to which the complaint relates
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Other documents supporting the complaint:
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Verżjoni bil-Malti — It-Tressiq ta' Lment

1.a. Informazzjoni dwar l-ilmentatur
Kunjom/Isem l-entità ġuridika:
Isem:
EUID jew jekk mhux disponibbli n-numru tar-Reġistrazzjoni jew tal-ID nazzjonali:
Identifikatur ta’ Entità Ġuridika (jekk disponibbli):
Referenza tal-klijent (jekk disponibbli):
Indirizz (triq, numru, sular) (għal entitajiet ġuridiċi, uffiċċju reġistrat):
Kodiċi postali:
Belt:
Pajjiż:
Telefown:
Indirizz tal-posta elettronika:
1.b. Id-dettalji ta\u2019 kuntatt (jekk differenti minn 1.a)
Kunjom/Isem l-entità ġuridika:
Isem:
Indirizz (triq, numru, sular) (għal entitajiet ġuridiċi, uffiċċju reġistrat):
Kodiċi postali:
Belt:
Pajjiż:
Telefown:
Indirizz tal-posta elettronika:
2.a. Informazzjoni dwar ir-rappre\u017centant legali (jekk applikabbli)
Kunjom/Isem l-entità ġuridika:
Isem:
Numru tar-reġistrazzjoni u LEI (jekk disponibbli):
Indirizz (triq, numru, sular) (Għal entitajiet ġuridiċi, uffiċċju reġistrat):
Kodiċi postali:
Belt:
Pajjiż:
Telefown:
Indirizz tal-posta elettronika:

prokura jew dokument uffi\u010bjali ie\u0127or b\u0127ala prova tal-\u0127atra tar-rappre\u017centant li g\u0127andu ji\u0121i pprovdut b\u0127ala dokument me\u0127mu\u017c ma' din il-formola

2.b. Id-dettalji ta\u2019 kuntatt (jekk differenti minn 2.a)
Kunjom/Isem l-entità ġuridika:
Isem:
Indirizz: triq, numru, sular (Għall-uffiċċju rreġistrat tad-ditti):
Kodiċi postali:
Belt:
Pajjiż:
Telefown:
Posta elettronika:
3. Informazzjoni dwar l-ilment
3.a. Referenza s\u0127i\u0127a tas-servizz tal-kriptoassi li mieg\u0127u huwa relatat l-ilment

ji\u0121ifieri l-isem tal-fornitur ta\u2019 servizzi tal-kriptoassi, in-numru tar-referenza tas-servizz tal-kriptoassi, jew referenzi o\u0127ra tat-tran\u017cazzjonijiet rilevanti\u2026

3.b. Deskrizzjoni tas-su\u0121\u0121ett tal-ilment

Ipprovdi kwalunkwe dokumentazzjoni li ssostni l-fatti msemmija.

3.c. Id-data(i) tal-fatti li wasslu g\u0127all-ilment
3.d. Id-deskrizzjoni tal-\u0127sara, it-telf jew id-dannu ikkaw\u017cati (fejn rilevanti)
3.e. Kummenti o\u0127ra jew l-informazzjoni rilevanti (fejn rilevanti)

Fi ___________________________________ (post) fi ___________________________________ (data)

FIRMA

ILMENTATUR/RAPPRE\u017bENTANT LEGALI TAL-ILMENTATUR

Dokumentazzjoni pprovduta (immarka l-kaxxa xierqa):
Prokura jew dokument uffiċjali ieħor bħala prova tal-ħatra tar-rappreżentant
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Kopja tad-dokumenti kuntrattwali tal-investimenti li għalihom jirreferi l-ilment
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Dokumenti oħra li jsostnu l-ilment:
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© 2026 Bequant Pro Limited. Complaints form template published pursuant to Commission Delegated Regulation (EU) 2025/294.