| futsal referee |  Dominik Cipiński |
| date of birth [dd/mm/yyyy] | - |
| nationality(ies) |  Polish |
| date | location | wdl | match | competition |
| 04/09/2021 | Bydgoszcz |
L | Poland - Brazil 1-5 | FM International Friendly |
| 19/09/2021 |  Helsingborg |
D | Sweden - Poland 3-3 | FW International Friendly |
| gms | pw | pd | pl | yp | avg yp | rp | avg rp | pfp (s) | pap (s) |
| 2 | 0 | 1 | 1 | 1 | 0.5 | 0 | 0.0 | 0 (0) | 0 (0) |