Breach Notification Form

Breach Notification Form
This form should be completed by firms where an adviser, who holds a current LIBF Statement of Professional Standing (SPS), is deemed to have breached FCA Regulations.

Representative Reporting the Breach
Please include information about your firm and the representative who informs us of this breach
Title
Name*

First NameMiddle NameLast Name
Job Title *
Email*
Preferred phone number*
Please enter a valid phone number
We will use this information to send an acknowledgement of your report and any other future correspondence in this matter. Are you happy for us to correspond with yourself?*

YesNo
Please give details of person you would like us to correspond with:

First NameMiddle NameLast Name
Email
example@example.com
Preferred phone number
Please enter a valid phone number

Adviser being reported
Please include information about the adviser who is being reported for a breach of FCA regulations.

The adviser needs to be aware that we may contact them directly in order to carry out our commitments to the FCA.
LIBF Number (if known)
Name

First NameLast Name
FCA Individual Reference Number (IRN)
SPS Expiry Date

DayMonthYear
Date
Job description within your firm:
Email
example@example.com
Preferred phone number
Please enter a valid phone number

Details of the Breach
Please detail below information you have supplied to the FCA which has not been already requested on this form. Including any actions taken / to be taken.

Updates
Firms can use this section to record any updates the AB may need to know in the progress of any breach and its investigations

Declaration
Your Personal Data

We will use and protect your personal data in accordance with current data protection legislation to evaluate your claim and make reasonable adjustments to your assessment where approved. We will share the information you have provided with appropriate members of staff and third parties where necessary to implement a reasonable adjustment. Further details, including your rights, the disclosure of data to third parties, storage, retention and how to amend your personal data, can be found within our Privacy Notice (www.libf.ac.uk/privacy).
Declaration - you must agree and accept the below to continue:*

I declare that the information contained in this form is true and accurate.I confirm that by completing and submitting this form and associated evidence, I give consent to the processing and secure storing of the evidence provided.
Signature*
Please sign to confirm you have read and agreed to the declaration above. A typed signature is acceptable .
Should be Empty: