A – Basic Information

1. Full name ______________________________________

____________________________________________________________

2. Name in a foreign language (if any)_____________

____________________________________________________________

3. Registered office address

4. Actual location

¨ the same as the registered office address

¨ other (please, specify)

5. Correspondence address

___ the same as the registered office address

___ the same as the actual location

___ other (please, specify)

6. Tel:

7. INN

FCC (Foreign Company Code) (for non-residents)

8. Account number

In regard to the account, I am:

____ Account holder

____ Authorised representative

____ Other ____________________

B – Declarations:

___ I declare that the entity is not a U.S. Person

___ I declare that the entity is not a financial institution (FI)

Note: 

FI (financial institution) means any financial institution that:

a) accepts deposits in the ordinary course of banking or a similar business;

b) holds financial assets for the account of others as a substantial portion of its business;

c) is engaged (holding itself out as being engaged) primarily in the business of investing, reinvesting, or trading in securities, partnership interests, commodities, derivatives (futures, options, forward contract etc.)

d) is an insurance company making payments on financial accounts.

Financial institution is engaged primarily in the business of investing, reinvesting, or trading if its gross income from such activities accounts for at least 50 % of its gross income for the last 2 years.

I declare that:

____ The entity's shares are traded on the stock exchange ___________________________________________

___ No U.S. Person (who owns more than 10 %) is the owner of the entity or the entity has disclosed information about its owners who are U.S. Persons (name, address, TIN of each person who owns more than 10 %)

Note: please specify the name and address of U.S. Persons in English

C – Confirmation of reliability of information provided and consent to transfer:

I declare that:

____ Information provided on this Questionnaire is true and accurate

____ The entity undertakes to inform you of any changes to the information provided within 30 days

____ The entity gives its consent to information transfer to the Internal Revenue Service (IRS), the Bank of Russia, Rosfinmonitoring and the FTS

Title, full name and signature of the entity's representative with the seal affixed

____________________________________________

____________________________________________

L.S.

Date of completion