Application Form for Declaration for a Dividend Payment and/or Profit Transfer

APPLICATION FORM FOR DECLARATION FOR A DIVIDEND PAYMENT AND/OR PROFIT TRANSFER (Based on the provisions, regulations, and conditions of the State Ordinance Foreign Exchange Transactions, AB 1990 No. GT 6) ________________________________________________________________________

1. Undersigned: _______________________________________________________________
   Address/Telephone/Fax: _______________________//
2. Application on behalf of: ______________________________________________________
   Resident/Nonresident (delete as appropriate)
   Address/Telephone: / A declaration for an outgoing dividend payment and/or outgoing profit transfer as referred to in the Notice concerning Foreign Exchange Transactions 24/L.1, paragraph III (b) and (c), for an amount of USD/Afl./EUR (choose as appropriate) __________ to_____________, domiciled in_____________________ :
   It concerns:
   Interim dividend
   (Final) dividend
   Profit transfer
   In respect of financial year (years):(fill out financial year (years)) A copy of the following documents has to be submitted together with this application:
   a. The financial statements in respect of the financial year or the financial years to which the dividend payment(s) and/or profit transfer(s) is/are related. b. The relevant shareholders’ resolution.
   c. The shareholders’ register.
   Truthfully filled out and signed without withholding any facts known by applicant and of importance to the application. / Applicant’s Signature / Date (day/month/year)