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2 4> 4>3>2>@C ! _______ 2V4 "___"___________ 2023 @>:C 2545=89 @>7@0EC=>: 20@B>ABV ! ?/?09<5=C20==O4. 2848=8FN, 3@=. 157 !C<0, 3@= 157 103><35 20W >?5@0FVW30 3#AC=5==O ?@>2VAC @59:8>?5@0FVW120 41AB565==O B5E=VG=>3> AB0=C :>;V9, >3;O4 B0 V=AB@C<5=B0;L=0 ?5@52V@:0 :>;VT2810<8 :>;V9 B0 AB@V;>G=8E ?5@52>4V2>?5@0FVW21 5#AC=5==O 2V4E8;5==O ?> H01;>=C>?5@0FVW50 6#AC=5==O ?@>A04:8 H?0;8>?5@0FVW120 7#AC=5==O ?0@=>W ?@>A04:8>?5@0FVW50 8V41820==O H?0;8>?5@0FVW60 9#AC=5==O 2V4E8;5==O ?> 30@0=BV9=V9 2V4AB0=V>?5@0FVW28 10#AC=5==O ?0@=>3> ?@>2VAC>?5@0FVW50 11015B>==>W>?5@0FVW10 12#AC=5==O ?@>2VAC 3>AB@O:0>?5@0FVW50 13#AC=5==O 7: >?5@0FVW80 14#AC=5==O :CBV2 2 ?;0=V>?5@0FVW10 15@82545==O 4> =>@<8 AB8:>28E 707>@V2>?5@0FVW20 160?5@0FVW25 17 53C;N20==O :@>:C D;N30@:8>?5@0FVW14 18#AC=5==O ;NDBC @>1>G>W BO38>?5@0FVW14 19#AC=5==O 1>:>2>3> CABC?C>?5@0FVW20 20#AC=5==O 25@B8:0;L=>3> CABC?C>?5@0FVW20 21#AC=5==O =0:0BV2 3>AB@O:0>?5@0FVW14 22#AC=5==O =0:0BV2 >A5@4O E@5AB>28=8>?5@0FVW14 23#AC=5==O =5?@8;O30==O ;V2>3> 3>AB@O:0>?5@0FVW14 24#AC=5==O =5?@8;O30==O ?@02>3> 3>AB@O:0>?5@0FVW14 250?5@0FVW15 26840;5==O 70A3> =5?@840B=>3> 4;O 5:A?;C0B0FVW 10;0ABC B0 ?>?>2=5=O G8AB8< 10;0AB>< (I51V=L D@0:FVW 20-40) :>;V9<31 27#AC=5==O 2V41>W2>?5@0FVW12 280:;04:8 ?V4 ?V4:;04:C (3C<>20)>?5@0FVW40 290:;04:8 ?V4 @59:C (3C<>20)>?5@0FVW40 30>BO6:0 3>@87>=B0;L=>3> 1>;B0>?5@0FVW70 31 5<>=B 720@=8E 7"T4=0=L <5B0;>:>=AB@C:FV9 70;V7=8G=8E 203>?5@0FVW4 320;B0 :;5<=>3> 7 309:>N>?5@0FVW20 330;B0 7 309:>N 4;O E@5AB>28= V :>;V9=8E @59>:>?5@0FVW10 34>BO6:0 70:;04=>3> 1>;B0>?5@0FVW50 35>BO6:0 :;5<=>3> 1>;B0>?5@0FVW50 360AB8;O :>;V9=>3>>?5@0FVW50 370;V9=>3> >?5@0FVW30 380?5@0FVW20 390B2.>?5@0FVW2 4002>W>?5@0FVW30 410 1>;B0 7 309:>N>?5@0FVW10 420;B0 AB8:>2>3> >?5@0FVW8 430W (AB8:>2>W)>?5@0FVW8 44>?>2=5==O I515=5< (D@0:FVO 5-20) =0 ?V4E>40E V 2A5@548=V 70;V7=8G=8E 203<30,3 450A:>W H0918>?5@0FVW15 AL>3> 157 : : * 07>< 7 :* *- 2@0E>2CTBLAO, O:I> 8:>=025FL T ?;0B=8:>< . ___________________/_________________ / ..&, ____________________ /_______________/ .. >40B>: ! 3 4> 4>3>2>@C ! _______ 2V4 "___"___________ 2023 @>:C >7@0EC=>: :>HB>@8A=>W 20@B>ABV 2V4 _________________20___@. ! ?/?!B0BBO 28B@0B (09<5=C20==O 28B@0B)&V=0, 3@=. 157 1AL>3> 157 : *:!, 7 *: *- 2@0E>2CTBLAO, O:I> 8:>=025FL T ?;0B=8:>< . ___________________/_________________ / ..&, ____________________ /_______________/ .. >40B>: !4 /Annex No4 4> >3>2>@C / to the Contract ! ______________________ 2V4 / dated ___________20__ =D>@<0FVO ?@> 2;0A=8:V2 :>=B@035=B0, 2:;NG0NG8 :V=F52>3> 15=5DVFV0@=>3> 2;0A=8:0 (:>=B@>;5@0) Information on Supplier s ownership structure, including ultimate beneficiary (controller) V7 707=0G5==O< 2AL>3> ;0=FN6:0 2;0A=8:V2, 2:;NG0NG8 :V=F528E 15=5DVFV0@=8E 2;0A=8:V2 (:>=B@>;5@V2) (Indicating entire ownership chain, including ultimate beneficiaries (controllers) AB0=>< =0/ as of «____»________20___@. (D>@<0/ Form) 09<5=C20==O >@30=V70FVW (=09<5=C20==O, 465==O, ) Company name (name, location, tax ID);0A=8:8 (0:FV>=5@8) >@30=V70FVW, V7 707=0G5==O< G0AB:8 2% (=09<5=C20==O, 465==O) Company owners (shareholders); indicate share % (name, location)V4B25@46CNGV 4>:C<5=B8, =09<5=C20==O @5:2V78B8, ?0A?>@B=V 40=V Confirmation documents, name, details, passport detailsI. V4?@8T-:>=B@035=B . SupplierII. .@848G=V >A>18, O:V T 2;0A=8:0<8 >@30=V70FVW :>=B@035=B0 . Legal entities that are Supplier s owners III. .@848G=V >A>18, O:V T 2;0A=8:0<8 =0ABC?=8E @V2=V2 (4> :V=F528E) . Legal entities that are owners at the following ownership levels (up to ultimate owners)IV. V=F5289 15=5DVFV0@=89 2;0A=8: (:>=B@>;5@) #. Ultimate beneficiary (controller) @8=5@V2 DV78G=8E >AV1 2:070B8 , , ?0A?>@B=V 40=V B0 G0AB:C 2 % ;O 2;0A=8:V2 / 0:FV>=5@V2 N@848G=8E >AV1 2:070B8: - =09<5=C20==O, D>@ABV, , 465==O B0 G0AB:C 2 % 2 >@30=V70FVW - 2:070B8 A2>WE 2;0A=8:V2 (4> :V=F528E) >AB>2V@=VABL B0 ?>2=>BC 40=>W V=D>@<0FVW ?V4B25@46CN. Indicate full name; tax ID, passport details of owners, beneficiaries and shareholders who are physical persons, including their share %. For owners/shareholders that are legal entities, indicate the following: - Name, form of ownership, tax ID, location and % of company share. - Indicate owners (up to ultimate owners). Hereby confirm the authenticity and completeness of this information V4?8A8 !B>@V= / Signatures of the Parties: V4 " "/ From the COUNTERPARTY:V4 " !"/ From the COMPANY: .. / Seal .. / Seal >40B>: ! 5 4> 4>3>2>@C ! _______ 2V4 "___"___________ 2023 @>:C !0=:FV9=5 70AB5@565==OSanction warning">20@8AB2>* <0T ?@02> 2 >4=>AB>@>==L>@O4:C 2V4<>28B8AO 2V4 28:>=0==O A2>WE 7>1>2 O70=L 70 >3>2>@>< B0/01> @>7V@20B8 >3>2V@ C 28?04:C, O:I>:The Company* has the right to unilaterally waive its obligations under the Agreement and / or terminate the Agreement if:- >=B@035=B* B0/01> 9>3> CG0A=8: B0/01> :V=F5289 15=5DVFV0@=89 2;0A=8: >=B@035=B0 2=5A5=89 4> A?8A:C A0=:FV9 OFAC !?>;CG5=8E (B0BV2 <5@8:8 (?5@5;V:C >AV1, 4> O:8E 70AB>A>20=V A0=:FVW, I> 287=0G0TBLAO The Office of Foreign Assets Control of the US Department of the Treasury);- The Counterparty* and / or its participant and / or the ultimate beneficial owner of the Counterparty is included in the list of OFAC sanctions imposed by the United States of America (The Office of Foreign Assets Control of the US Department of Treasury constitutes the list of persons subject to sanctions);- > >=B@035=B0 B0/01> CG0A=8:0 >=B@035=B0 B0/01> :V=F52>3> 15=5DVFV0@=>3> 2;0A=8:0 >=B@035=B0 B0/01> B>20@V2 G8 ?>A;C3 >=B@035=B0 70AB>A>20=V >1<565==O (A0=:FVW) V=H8E, =V6 OFAC, 45@602=8E >@30=V2 !(, @568< 4>B@8<0==O O:8E <>65 1CB8 ?>@CH5=89 28:>=0==O< >3>2>@C;- The Counterparty and / or Counterparty's participant and / or the ultimate beneficial owner of the Counterparty and / or the Counterparty's goods or services are subject to restrictions (sanctions) other than OFAC, as imposed by US government authorities, the compliance with which may be violated by performance of this Agreement;- >=B@035=B B0/01> CG0A=8: >=B@035=B0 B0/01> :V=F5289 15=5DVFV0@=89 2;0A=8: >=B@035=B0 2=5A5=89 4> A?8A:C A0=:FV9 2@>?59AL:>3> !>N7C (Consolidated list of persons, groups and entities subject to EU financial sanctions);- The Counterparty and / or Counterparty's participant and / or ultimate beneficial owner of the Counterparty is included in the list of sanctions imposed by the European Union (Consolidated list of persons, groups and entities subject to EU financial sanctions);- >=B@035=B B0/01> CG0A=8: >=B@035=B0 B0/01> :V=F5289 15=5DVFV0@=89 2;0A=8: >=B@035=B0 2=5A5=89 4> A?8A:C A0=:FV9 Her Majesty's Treasury 5;8:>W @8B0=VW (A?8A:C >AV1, 2:;NG5=8E 2 «Consolidated list of financial sanctions targets in the UK» B0 2 «List of persons subject to restrictive measures in view of Russia's actions destabilizing the situation in Ukraine», I> 2545BLAO the UK Office of Financial Sanctions Implementation (OFSI) of the Her Majesty's Treasury);- The Counterparty and / or Counterparty's participant and / or ultimate beneficial owner of the Counterparty is included in Her Majesty's Treasury Sanctions List imposed by the UK (list of persons included in the «Consolidated list of financial sanctions targets in the UK» and in the «List of persons subject to restrictive measures in view of Russia's actions destabilizing the situation in Ukraine» that are constituted by the UK Office of Financial Sanctions Implementation (OFSI) of Her Majesty's Treasury);- >=B@035=B B0/01> CG0A=8: >=B@035=B0 B0/01> :V=F5289 15=5DVFV0@=89 2;0A=8: >=B@035=B0 2=5A5=89 4> A?8A:C A0=:FV9 048 57?5:8 (72545=>3> A?8A:C A0=:FV9 048 57?5:8 @30=V70FVW 1 T4=0=8E 0FV9 (Consolidated United Nations Security Council Sanctions List), 2 O:89 2:;NG5=V DV78G=V B0 N@848G=V >A>18, I>4> O:8E 70AB>A>20=V A0=:FV9=V 70E>48 048 57?5:8 ). - >=B@035=B B0/01> CG0A=8: >=B@035=B0 B0/01> :V=F5289 15=5DVFV0@=89 2;0A=8: >=B@035=B0 2=5A5=89 4> A?8A:C A0=:FV9 048 =0FV>=0;L=>W 157?5:8 V >1>@>=8 #:@0W=8 (?5@5;V:C >AV1, 4> O:8E 04>N =0FV>=0;L=>W 157?5:8 V >1>@>=8 #:@0W=8 70AB>A>20=V ?5@A>=0;L=V A?5FV0;L=V 5:>=>1<56C20;L=V 70E>48 (A0=:FVW), 2V4?>2V4=> 4> AB0BBV 5 0:>=C #:@0W=8 «@> A0=:FVW» @VH5==O<8, O:V 22545=V 2 4VN #:070<8 @57845=B0 #:@0W=8). - The Counterparty and / or the Counterparty's participant and / or the ultimate beneficial owner of the Counterparty is included in the United Nations Security Council Sanctions List (the Consolidated United Nations Security Council Sanctions List) that includes individuals and legal entities, subject to UN Security Council sanctions). - The Counterparty and / or the Counterparty's participant and / or the ultimate beneficial owner of the Counterparty is included in the list of sanctions imposed by the decisions of the National Security and Defense Council of Ukraine (list of persons subject to personal special economic and other restrictive measures of National Security and Defense Council of Ukraine under Article 5 of the Law of Ukraine «On Sanctions» as put into effect by the Decrees of the President).- )>4> B>20@V2 B0/01> ?>A;C3 70 >3>2>@>< B0/01> I>4> 28:>=0==O V=H8E C<>2 >3>2>@C 04>N =0FV>=0;L=>W 157?5:8 V >1>@>=8 #:@0W=8 70AB>A>20=V ?5@A>=0;L=V A?5FV0;L=V 5:>=>1<56C20;L=V 70E>48 (A0=:FVW), 2V4?>2V4=> 4> AB0BBV 5 0:>=C #:@0W=8 «@> A0=:FVW» @VH5==O<8, O:V 22545=V 2 4VN #:070<8 @57845=B0 #:@0W=8), C 28?04:C, O:I> 28:>=0==O >3>2>@C AC?5@5G8B8<5 4>B@8<0==N A0=:FV9 048 =0FV>=0;L=>W 157?5:8 V >1>@>=8 #:@0W=8. - The National Security and Defense Council of Ukraine applies personal special economic and other restrictive measures (sanctions) to goods and / or services under the Agreement and / or to the performance of other provisions of the Agreement, in accordance with Article 5 of the Law of Ukraine «On Sanctions» that are put into effect by the Decrees of the President of Ukraine), if the implementation of the Agreement violates the compliance with the sanctions imposed by the National Security and Defense Council of Ukraine. ">20@8AB2> <0T ?@02> 2 >4=>AB>@>==L>@O4:C 2V4<>28B8AO 2V4 28:>=0==O A2>WE 7>1>2 O70=L 70 >3>2>@>< B0/01> @>7V@20B8 >3>2V@ C 28?04:C, O:I> AB0=5 2V4><>, I>: The Company has the right to unilaterally waive its obligations under the Agreement and / or terminate the Agreement in case it becomes known that:- 8@>1=8: B>20@C B0/01> :V=F5289 15=5DVFV0@=89 2;0A=8: 8@>1=8:0 2=5A5=89 4> A?8A:C A0=:FV9 048 =0FV>=0;L=>W 157?5:8 V >1>@>=8 #:@0W=8 (?5@5;V:C >AV1, 4> O:8E 04>N =0FV>=0;L=>W 157?5:8 V >1>@>=8 #:@0W=8 70AB>A>20=V ?5@A>=0;L=V A?5FV0;L=V 5:>=>1<56C20;L=V 70E>48 (A0=:FVW), 2V4?>2V4=> 4> AB0BBV 5 0:>=C #:@0W=8 «@> A0=:FVW» @VH5==O<8, O:V 22545=V 2 4VN #:070<8 @57845=B0 #:@0W=8);- The Producer and/or the ultimate beneficial owner of the Producer is included in the list of sanctions imposed by the decisions of the National Security and Defense Council of Ukraine (list of persons subject to personal special economic and other restrictive measures of National Security and Defense Council of Ukraine under Article 5 of the Law of Ukraine «On Sanctions» as put into effect by the Decrees of the President);- 8@>1=8: B>20@C 2=5A5=89 4> A?8A:C A0=:FV9 2@>?59AL:>3> !>N7C (Consolidated list of persons, groups and entities subject to EU financial sanctions);- The Producer is included in the list of sanctions imposed by the European Union (Consolidated list of persons, groups and entities subject to EU financial sanctions);- 8@>1=8: B>20@C 2=5A5=89 4> A?8A:C A0=:FV9 Her Majesty's Treasury 5;8:>W @8B0=VW (A?8A:C >AV1, 2:;NG5=8E 2 «Consolidated list of financial sanctions targets in the UK» B0 2 «List of persons subject to restrictive measures in view of Russia's actions destabilizing the situation in Ukraine», I> 2545BLAO the UK Office of Financial Sanctions Implementation (OFSI) of the Her Majesty's Treasury);- The Producer is included in Her Majesty's Treasury Sanctions List imposed by the UK (list of persons included in the «Consolidated list of financial sanctions targets in the UK» and in the «List of persons subject to restrictive measures in view of Russia's actions destabilizing the situation in Ukraine» that are constituted by the UK Office of Financial Sanctions Implementation (OFSI) of Her Majesty's Treasury);- 8@>1=8: B>20@C 2=5A5=89 4> A?8A:C A0=:FV9 048 57?5:8 (72545=>3> A?8A:C A0=:FV9 048 57?5:8 @30=V70FVW 1 T4=0=8E 0FV9 (Consolidated United Nations Security Council Sanctions List), 2 O:89 2:;NG5=V DV78G=V B0 N@848G=V >A>18, I>4> O:8E 70AB>A>20=V A0=:FV9=V 70E>48 048 57?5:8 ).- The Producer is included in the United Nations Security Council Sanctions List (the Consolidated United Nations Security Council Sanctions List) that includes individuals and legal entities, subject to UN Security Council sanctions).- >=B@035=B =5 ?>2V4><82 ">20@8AB2> ?@> 7=B@035=B0, 70A=>2=8:0, :V=F52>3> 15=5DVFV0@=>3> 2;0A=8:0 (:>=B@>;5@0), CG0A=8:0, 0:FV>=5@0, O:>=B@035=B0 ?>=04 10% ?@>BO3>< 5 (? OB8) @>1>G8E 4=V2 2V4 40B8 B0:8E 720 2V4 28:>=0==O 7>1>2 O70=L 70 >3>2>@>< B0/01> @>7V@20==O >3>2>@C ">20@8AB2>< 2V41C20TBLAO H;OE>< =0?@02;5==O >=B@035=BC ?8AL<>2>3> ?>2V4><;5==O. >3>2V@ 22060TBLAO @>7V@20=8< =0 5 (? OB89) @>1>G89 45=L 7 40B8 2V4?@02;5==O >=B@035=BC B0:>3> ?>2V4><;5==O ">20@8AB2><. 0B>N 2V4?@02;5==O ?>2V4><;5==O 22060TBLAO 40B0, 707=0G5=0 2 4>:C<5=BV (2 B> DVA:0;L=89 G5:, :28B0=FVO, =0:;04=0, >?8A 2:;045==O 2 FV==89 ;8AB, 45:;0@0FVO) ?V4?@8T2V4><;5==O.The Company refuses to fulfill the obligations under the Agreement and / or terminates the Agreement by sending a notice to the Counterparty in writing. The Agreement is deemed as terminated on the 5th (fifth) business day from the date of dispatch of such notice to the Counterparty by the Company. Date of sending the notice of termination of the Contract unilaterally, which is the date of departure specified in the document of the telecommunications company, through which such notice is sent (including, but not limited to, fiscal check, receipt, invoice, description of attachment to the envelope, declaration). *">20@8AB2> " «#:@307284>1C20==O». *>=B@035=B >A>10 7 O:>N " «#:@307284>1C20==O» C:;045=> >3>2V@. * Company - JSC «Ukrgasvydobuvannya». * Counterparty - a person with whom JSC «Ukrgasvydobuvannya» has entered into an Agreement. V4?8A8 !B>@V= / V4 &//From the PERFORMER: _______________________ /________ / .. / Seal Signatures V4 / From the CUSTOMER: _______________________ /________ / .. / Seal tÒÚÕvÐÒ"$Â"$P68Â!^'`'4(6(^(p(r(²(´(ø(ïíïÜËÜËïºïÜËÜËÜ©Ü˜©Ü©‡ufWfWfh£_–h®YÅCJOJQJ^Jh£_–hƒc‡CJOJQJ^J#h£_–h®-x5CJOJQJ^JaJ h£_–hSj%CJOJQJ^JaJ h£_–hèsƒOJQJ^JmH"sH" h£_–hèsƒCJOJQJ^JaJ h£_–h !kOJQJ^JmH"sH" h£_–hõàCJOJQJ^JaJ h£_–hlZ¸CJOJQJ^JaJU h£_–hlZ¸OJQJ^JmH"sH"4(6(^( (ø(X)D*Ž**Ü*î*+óÜ¾¾¾¾¾¨‘}q$$Ifa$gdÿÝ$ ÆÄ¤¤$Ifa$gdÿÝ$ &F Æn„„^„`„a$gdÿÝ$ Æ Sn„„7]„`„7a$gdÿÝ$ &F Æ Sn„„„7]„^„`„7a$gdÿÝ$ &F Æn„„7^„`„7a$gdÿÝ$„7`„7a$gdÿÝø()))X)Z)n)p)r)t)€)‚)>*@*B*D**Ü*ì*î*++ñâñÓñÄñµ¦—ÄˆÄµÄÓvdR@v#h£_–hX'(5CJOJQJ^JaJ#h£_–h®-x6CJOJQJ^JaJ#h£_–hX'(6CJOJQJ^JaJ#h£_–h®-x5CJOJQJ^JaJh£_–h{%©CJOJQJ^Jh£_–ha+iCJOJQJ^Jh£_–h×ÂCJOJQJ^Jh£_–h-6¹CJOJQJ^Jh£_–h®-xCJOJQJ^Jh£_–h™užCJOJQJ^Jh£_–h®YÅCJOJQJ^Jh£_–hQ½CJOJQJ^J++4+¦+¨+ª+«——‹7Skd©$$IfT–l”Ö0”ÿÃ&€ˆÿÿÿÿ€§ö/'ööÖÿÿÖÿÿÖÿÿÿÿÿÖÿÿ4Ö laöytp:ÝŠT$$Ifa$gdÿÝ$ ÆÄ¤¤$Ifa$gdÿÝSkd$$IfT–l”Ö0”ÿÃ&€ˆÿÿÿÿ€§ö/'ööÖÿÿÖÿÿÖÿÿÿÿÿÖÿÿ4Ö 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