ACT ADITIONAL

la Contractul de vanzare-cumparare
nr. _____/_________
(Contractul)

ADDENDUM
to the Sale and Purchase Contract
no. ______/_________
(the Contract)

Prezentul act aditional s-a incheiat intre:

This Addendum was entered into by and between:

S.C. ROMPETROL DOWNSTREAM S.R.L., cu sediul in

Bucuresti, cod postal 013702, Piata Presei Libere nr. 3-5,
City Gate Northern Tower Building, etaj 2, sector 1, tel. 021
206.75.00, fax 021 206.75.80, inmatriculata la Oficiul
Registrului Comertului Bucuresti sub nr. J40/1716/2000, CIF
RO12751583, cont nr. RO77RNCB0072001339140001
deschis la BCR Sector 1 Bucuresti, reprezentata legal prin
prin ________________________________________ in
calitate
de
________________________________
si
______________________________________ in calitate
de _______________________________, denumita in cele
ce urmeaza Vanzator,
Si

S.C. ROMPETROL DOWNSTREAM S.R.L., headquartered

in Bucharest, postal code 013702, 3-5 Piata Presei Libere,
City Gate Northern Tower Building, 2nd floor, District 1, tel.
021 206.75.00, fax 021 206.75.80, registered with the
Bucharest Trade Registry under no. J40/1716/2000, CIF RO
12751583,
having
the
IBAN
account
no.
RO77RNCB0072001339140001 opened with BCR Sector 1
Bucharest, duly represented by _____________________
as _____________________________________ and by
______________________________________
as
_________________________________,
hereinafter
referred to as the Seller,
And

S.C. ______________________________, cu sediul in

________________________________________________
inmatriculata la Oficiul Registrului Comertului sub
nr. J _______________, CIF RO___________________,
cont IBAN nr. ____________________________________
deschis
la
_____________________________,
reprezentata legal prin ________________________ in
calitate
de
_______________________________
si
__________________________________ in calitate de
_______________________________ denumita in cele ce
urmeaza Cumparator,

S.C.
______________________________,
headquartered in __________________________________
_______________________________________ registered
with the Trade Registry under no. J ___________________,
CIF RO______________________, IBAN account no.
_________________________________
opened
with
__________________________, duly represented by
_____________________________
as
__________________________________
and
by
_______________________________________
as
_________________________________ in capacity of
buyer, hereinafter referred to as Buyer,

Avand in vedere ca intre parti s-a incheiat Contractul de

vanzare-cumparare nr. ___________ (Contractul), astfel
cum a fost modificat prin acte aditionale subsecvente,

Whereas the Parties concluded the Sale and Purchase

Contract no. ____________ (hereinafter the Contract), as
amended by all further addenda attached thereto,

Avand in vedere ca partile au inteles sa prelungeasca

valabilitatea conditiilor comerciale cuprinse in politica
comerciala promovata de catre Vanzator in anul 2011, pana
la incheierea prezentului act aditional,

Whereas the Parties understood to extend the validity of the

commercial terms comprised under the commercial policy
promoted by the Seller in 2011 up to the conclusion of this
Addendum,

Avand in vedere politica comerciala pe care Vanzatorul

intentioneaza sa o implementeze in anul 2012,

Having regard to the commercial policy that the Seller

intends to implement in 2012,

Avand in vedere optiunea manifestata de catre Cumparator

de a beneficia de avantajele oferite de catre Vanzator prin
politica comerciala wholesale to consumer pe care
Vanzatorul intentioneaza sa o implementeze in anul 2012

Having regard to the option manifested by the Buyer to

benefit from the advantages provided by the Seller under
the wholesale to consumer commercial policy that the
latter intends to implement in 2012

Avand in vedere scopul achizitionarii de catre Cumparator a

produselor petroliere de la Vanzator, respectiv achizitia
engros exclusiv pentru consumul propriu,

Having regard to the purpose for which the Buyer purchased

the oil products from the Seller, and namely to buy such
products
wholesale
exclusively
for
its
own
consumption,

Prtile convin modificarea Contractului, in urmatoarele

conditii :

Now, the Parties hereby agree upon the amendment of the

Contract, under the following terms and conditions:

Art. 1. Cumparatorul se angajeaza sa cumpere, iar

Vanzatorul se angajeaza sa livreze, pe perioada cuprinsa
intre ______________ si pana la 28.02.2013, sau pana la
adoptarea politicii comerciale a Rompetrol valabila in anul
2013 (daca aceasta nu este adoptata pana la 28.02.2013)
produse petroliere, in conditiile comerciale stabilite mai jos.

Art.
1.
Throughout
the
period
starting
with
_______________ and until February 28, 2013, or until
Rompetrol commercial policy valid in 2013 is adopted
(unless such policy has been adopted by February 28,
2013), the Buyer undertakes to purchase, and the Seller
undertakes to deliver oil products, in accordance with the
herein below terms and conditions.

Art 2. Pretul de vanzare este pretul de referinta

WHOLESALE (Depozit) valabil in depozitul Vanzatorului la
data la care marfa este livrata si facturata din depozitul

Art. 2. The sales price is the reference WHOLESALE

(Warehouse) price valid in the Sellers warehouse on the
date when the merchandise is delivered from the Sellers

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pag 1/5

Vanzatorului si trece in proprietatea Cumparatorului prin

individualizare in depozitul Vanzatorului. Pretul este stabilit
pe unitate de 1.000 (una mie) litri, la temperatura de 15
grade Celsius.

warehouse and is transferred into the property of the Buyer

by individualization in the Sellers Warehouse. The Price is
established per unit at 1,000 (one thousand) liters, at a
temperature of 15 degrees Celsius.

Art. 3. Pentru fiecare livrare in parte, Cumparatorul va

emite o comanda scrisa, in care se vor mentiona atat
cantitatea achizitionata, cat si termenul de plata solicitat.
Comanda va fi transmisa cu cel putin 24 ore inainte de data
livrarii. Cumparatorul efectueaza plata in avans sau, in cazul
in care Vanzatorul acorda Cumparatorului credit comercial,
prin fila CEC depusa la livrarea marfii completata conform
facturii de livrare in termen de maxim 21 zile de la data
emiterii facturii.

Art. 3. For each separate delivery, the Buyer shall issue a

written order, whereby it shall specify both the quantity to
be purchased, and the requested payment term. The written
order shall be transmitted at least 24 hours before the
delivery date. The Buyer pays in advance or, if the Seller
grants the Buyer commercial credit, through a cheque filled
in according to the delivery invoice deposited upon the
delivery of the goods within not more than 21 days as of the
invoicing date.

Art. 4. La pretul de facturare la livrare Vanzatorul acorda

urmatoarele discount-uri, in conditiile de mai jos:

Art. 4. With respect to the invoice price upon delivery, the

Seller shall grant the following discounts, in accordance with
the terms herein below:
1. GUARANTEED DISCOUNT (VAT exclusive):
The Seller shall grant to the Buyer upon delivery a discount
of 10$ USD/cubic meter (VAT exclusive). The discount shall
not be granted if the Beneficiary records overdue for any
invoices.
2. ADDITIONAL VOLUME-RELATED DISCOUNT
(VAT exclusive) :
-------------------------------------------------Monthly volume
Additional discount
cubic meter
USD/cubic meter
-------------------------------------------------10 - 30
6 USD
31-60
10 USD
61-100
15 USD
>100
20 USD
-------------------------------------------------The additional volume-related discount shall be granted
based on the quantity of oil products purchased throughout
a calendar month. The discount shall not be granted in case
the Buyer records overdue.

1. DISCOUNT GARANTAT (fara TVA) :

Vanzatorul acorda Cumparatorului un discount la livrare in
cuantum de 10 USD/mc (fara TVA). Discountul nu se acorda
in cazul in care Cumparatorul inregistreaza intarzieri la plata
oricaror facturi.
2. DISCOUNT SUPLIMENTAR DE VOLUM (fara
TVA) :
-------------------------------------------------Volum lunar
Disc suplim
mc
USD/mc
-------------------------------------------------10 - 30
6 USD
31-60
10 USD
61-100
15 USD
>100
20 USD
-------------------------------------------------Discountul suplimentar de volum se acorda in functie de
cantitatea de produse petroliere achizitionata pe parcursul
unei luni calendaristice. Discountul de volum nu se acorda in
cazul in care Cumparatorul inregistreaza pe parcursul lunii
de referinta intarzieri la plata.
3. DISCOUNT SUPLIMENTAR PENTRU PLATA
INTEGRALA IN AVANS:
Vanzatorul acorda Cumparatorului la livrare un discount
suplimentar de 10$ USD/mc (fara TVA), exclusiv pentru
volumele la care s-a facut plata integrala in avans.
Discountul nu se acorda in cazul in care Cumparatorul
inregistreaza intarzieri la plata oricaror facturi.
4.

DISCOUNT SUPLIMENTAR PENTRU PLATA

INTEGRALA LA LIVRARE
Vanzatorul acorda Cumparatorului la livrare un discount
suplimentar de 5 USD/mc (fara TVA), exclusiv pentru
volumele la care s-a facut plata integrala prin fila CEC
depusa la livrare, avand scadenta in ziua livrarii. Acest
discount nu se acorda in cazul in care Cumparatorul
inregistreaza intarzieri la plata facturilor emise de Vanzator.

5.

DISCOUNT
SUPLIMENTAR
PENTRU
GARANTAREA CREDITULUI COMERCIAL:

Daca intreaga valoare a creditului comercial acordat de

Vanzator este garantata de catre Cumparator prin scrisoare
de garantie bancara sau prin depunerea in contul
Vanzatorului a sumei garantate, in plus fata de discounturile
acordate, Vanzatorul acorda Cumparatorului la livrare un
discount suplimentar de 10 USD/mc fara TVA pentru
cantitatile achizitionate in perioada in care aceasta conditie
este indeplinita. Discountul nu se acorda pentru cantitatile
achizitionate cu plata in avans si nu se cumuleaza cu

ADDITIONAL DISCOUNT FOR FULL PAYMENT

IN ADVANCE:
The Seller shall grant to the Buyer upon delivery an
additional discount
of 10$ USD/cubic meter (VAT
exclusive), exclusively for the volumes the payment of
which has been effected in advance. The discount shall not
be granted if the Beneficiary records overdue for any
invoices.
4. ADDITIONAL DISCOUNT FOR FULL PAYMENT
UPON DELIVERY:
The Seller shall grant to the Buyer upon delivery for the
quantities purchased with payment upon term an additional
discount
of 5 $ USD/cubic meter (VAT exclusive),
exclusively for the volumes the payment of which has been
effected by means of a cheque deposited on the delivery
date and having as due date the delivery date. This discount
shall not be granted if the Buyer records overdue for the
invoices issued by the Seller.
5. ADDITIONAL DISCOUNT FOR THE GUARANTEE
OF THE COMMERCIAL CREDIT:
In the event that the entire amount of the commercial credit
granted by the Seller is secured by the Buyer through a
bank guarantee letter or by depositing the secured amount
into the Sellers account, in addition to the granted
discounts, the Seller shall also grant to the Buyer upon
delivery for the quantities purchased with payment upon
term an additional discount of 10 USD/cubic meter, VAT
exclusive, for the quantities purchased throughout the
period in which such requirement is met. The discount is not
granted for the quantities purchased with payment in

02012012 Act Aditional W2C (1) - Rompetrol Downstream PC 2012

3.

pag 2/5

discountul suplimentar pentru plata integrala la livrare.

Discountul nu se acorda in cazul in care Cumparatorul
inregistreaza intarzieri la plata oricaror facturi.

6.

DISCOUNT IN FUNCTIE DE DEPOZITUL DE

LIVRARE
Daca intreaga valoare a creditului comercial acordat de
Vanzator este garantata de catre Cumparator prin scrisoare
de garantie bancara sau prin depunerea in contul
Vanzatorului a sumei garantate sau daca Cumparatorul
efectueaza plata in avans, in plus fata de discounturile
acordate, Vanzatorul acorda Cumparatorului la livrare un
discount dupa cum urmeaza:
Livrari
din
Vanzatorului

Depozitul

Valoarea
discountului
(USD/mc)
20

Navodari/Rompetrol
Rafinare
Mogosoaia
15
Almaj
10
Zarnesti
10
Vatra Dornei
6
Discountul nu se acorda in cazul in care Cumparatorul
inregistreaza intarzieri la plata oricaror facturi.

advance and cannot be cumulated with the additional

discount for the guarantee of the commercial credit. This
discount shall not be granted if the Buyer records overdue
for the invoices issued by the Seller.
6.

DISCOUNT DEPENDING ON THE DELIVERY

WAREHOUSE
In the event that the entire amount of the commercial credit
granted by the Seller is secured by the Buyer through a
bank guarantee letter or by depositing the secured amount
into the Sellers account or the Buyer makes the payments
in advance, in addition to the discounts granted, the Seller
grants the Buyer upon delivery a discount as follows:
Deliveries
from
Sellerss warehouse
Navodari/Rompetrol
Rafinare
Mogosoaia
Almaj
Zarnesti
Vatra Dornei

the

Discount value
(USD/mc)
20
15
10
10
6

This discount shall not be granted if the Buyer records

overdue for the invoices issued by the Seller.

Art. 5. Discounturile acordate la sfarsitul lunii/trimestrului

se vor calcula la cursul de schimb BNR valabil in penultima
zi lucratoare a lunii calendaristice pentru care se acorda
discountul. Discounturile acordate la livrare se vor calcula la
cursul de schimb BNR valabil in ziua facturarii carburantului
achizitionat.

Art. 5. The discounts granted at the end of the

month/trimester shall be computed at the NBR exchange
rate valid on the penultimate working day of the calendar
month with respect to which the said discount is granted.
The discounts granted upon delivery shall be computed at
the NBR exchange rate valid on the day the fuel was
invoiced.

Art. 6. Daca valoarea creditului comercial nu este garantata

in intregime prin scrisoare de garantie bancara sau prin
depunerea in contul Vanzatorului a sumei garantate, si
Cumparatorul nu efectueaza plata in avans, Vanzatorul va
factura Cumparatorului, in plus fata de pretul carburantilor
astfel cum este prevazut in contract, 8 USD/mc fara TVA.
Cursul de schimb va fi cursul BNR valabil in ziua facturarii
carburantului achizitionat.

Art. 6. In the event that the entire amount of the

commercial credit granted by the Seller is not secured by
the Buyer through a bank guarantee letter or by depositing
the secured amount into the Sellers account and the Buyer
does not make the payment in advance, the Seller shall
invoice, in addition to the fuel price as stipulated in the
contract, 8 USD/cubic meter VAT exclusive. The exchange
rate shall be NBR exchange rate valid on the day the fuel
was invoiced.

Art. 7. Exclusiv pentru cantitatile de carburant pentru care

au fost facturate sumele prevazute in alineatul precedent, in
cazul in care la sfarsitul lunii calendaristice urmatoare celei
in care sunt achizitionate cantitatile se constata ca in
ultimele doua luni nu au fost inregistrate intarzieri la plata
oricarei facturi, Vanzatorul va acorda un bonus pentru
indeplinirea obligatiilor de plata la termen in valoare de 10
USD/mc fara TVA. Bonusul se va calcula la cursul de schimb
BNR valabil in penultima zi lucratoare a lunii calendaristice
pentru care se acorda.

Art. 7. Exclusively for the quantities of fuel for which the

amounts stipulated in the previous paragraph were invoiced,
in case at the end of the calendar month following the
month in which the quantities were purchased, it is
acknowledged that during the last two months there were
no overdue on payment of the invoices, the Seller shall
grant a bonus for observing the payment obligation in term
in amount of 10 USD/cubic meter VAT exclusive. The bonus
shall be computed at the NBR exchange rate valid on the
working day prior to the last day of the calendar month in
which is granted.

Conditiile comerciale specificate in prezentul Act Aditional isi

produc efectele din ____________ si pana la 28 februarie
2013 sau pana la momentul intrarii in vigoare a politicii
comerciale Rompetrol aferenta anului 2013 (daca aceasta
nu este adoptata pana la 28 februarie 2013).

The commercial terms contemplated within this Addendum

shall be effective starting _____________ and until
February 28, 2013 or until the coming into force of
Rompetrol commercial policy for 2013 (unless such policy
has been adopted by February 28, 2013).

Art. 8. Vanzatorul poate acorda Cumparatorului credit

comercial, caz in care acesta din urma garanteaza creditul
comercial acordat de catre Vanzator prin una din garantiile
mentionate mai jos:
- Cec avalizat de o societate bancara in favoarea
Vanzatorului/Cec certificat de o societate bancara;

Art. 8. The Seller may grant to the Buyer a commercial

credit, in which case the latter shall secure such credit
granted by the Seller through one of the following
guarantees:
- Cheque guaranteed by a banking company in favour of the
Seller/cheque endorsed by a banking company;

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- Ipoteca de rang I asupra unei statii de carburant

apartinand Cumparatorului. Ipoteca astfel constituita
urmeaza a fi inregistrata la Cartea Funciara tinuta de oficiile
de cadastru si publicitate imobiliara competente.
- Scrisoare de Garantie Bancara;
- Factura de garantie (depunerea in contul Vanzatorului a
sumei garantate)
In cazul emiterii unei scrisori de garantie bancara, in
favoarea
Vanzatorului,
comenzile
emise
de
catre
Cumparator vor fi onorate numai in masura in care garantia
constituita prin scrisoare de garantie bancara va putea fi
activata in termenele de plata solicitate pentru fiecare
comanda in parte.

- First rank mortgage over a fuel distribution station

property owned by the Buyer. The mortgage so established
shall be registered with the Land Book held by the
competent cadastre and real estate publicity offices.- Bank
Guarantee Letter;
- Security invoice (depositing the secured amount into the
Sellers account)
If a bank guarantee letter is issued in favour of the Seller,
the orders issued by the Buyer shall be carried out only to
the extent to which the guarantee created under the bank
guarantee letter may be enforced within the payment terms
requested for each separate order.

Art. 9. Avand in vedere ca instrumentele de plata si/sau

scrisoare de grantie bancara predate de Cumparator
Vanzatorului nu pot fi decontate partial de catre bancile
comerciale, in cazul in care, la data scadentei, debitul
Cumparatorului fata de Vanzator este mai mic decat suma
inscrisa pe instrumentul de plata, Vanzatorul are dreptul sa
introduca la plata instrumentul respectiv, iar Cumparatorul
isi asuma toata responsabilitatea pentru acest lucru
indiferent de consecintele introducerii la plata a
instrumentului respectiv. Diferenta intre suma inscrisa pe
instrumentul de plata si valoarea debitului va fi returnata
imediat de Vanzator dupa incasarea debitului.

Art. 9. Considering that the payment instruments and/or

the bank guarantee letter submitted by the Buyer to the
Seller cannot be partially settled by commercial banks, in
the event that, on the due date thereof, the Buyers debt
towards the Seller is smaller than the amount in the
payment instrument, the Seller shall be entitled to enforce
the respective instrument, whereas the Buyer undertakes
full responsibility in this respect regardless of the
consequences triggered by the enforcement of such
instrument. The difference between the amount indicated by
the payment instrument and the debt value shall be
immediately reimbursed by the Seller after having cashed
the debt.

Art. 10. Orice plati primite de Vanzator de la Cumparator

vor fi alocate pentru stingerea obligatiilor Cumparatorului,
conform oricarui contract incheiat intre cele doua parti,
indiferent de obiectul raportului juridic, in urmatoarea
ordine: i) dobanzi si penalitati, ii) obligatii de despagubire,
iii) obligatii principale, de fiecare data in ordinea vechimii
acestora in fiecare categorie, incepand cu cea mai veche iv)
cheltuielile de judecata, onorariu avocat, taxe de timbru,
comisioane de succes, (v) alte obligatii.

Art. 10. Any payments received by the Seller from the

Buyer according to any contract concluded between the two
parties, irrespective of the scope of legal relationship, shall
be allotted for the discharge of the obligations of the Buyer
in the following order: i) interests and penalties, ii)
indemnification obligations, iii) principal obligations, in each
case considered according to their date, starting with the
earliest, iv) court expenses, attorney fees, stamp duties,
success fees, (v) other obligations.

Art. 11. In cazul executarii cu intarziere a obligatiilor de

plata de catre Cumparator, Cumparatorul va suporta daune
moratorii in cuantum de 0,1% per zi de intarziere din
valoarea facturii neachitate. Penalitatile de intarziere nu for
fi plafonate la suma asupra careia sunt calculate.
In cazul in care Cumparatorul nu isi indeplineste integral si
la termen obligatia de plata a facturilor emise de Vanzator
conform oricarui contract incheiat intre cele doua parti,
toate sumele reprezentand contravaloarea produselor
achizitionate de catre cumparator, indiferent de obiectul
raportului juridic, devin imediat scadente.

Art. 11. In case the Buyer executes his payment obligation

with delay, the Buyer shall incur delay penalties in the
amount of 0.1% per day of delay from the value of the
unpaid invoice. The delay penalties shall not be limited to
the amount upon which they are computed.
If the Buyer fails to exhaustively and timely fulfill the
obligation to pay the invoices issued by the Seller according
to any contract concluded between the two parties, all
amounts representing the value of the products purchased
by the Buyer, irrespective of the scope of legal relationship,
shall immediately become due.

Art. 12. Vanzatorul are dreptul sa rezilieze Contractul de

plin drept, pe baza de notificare, fara interventia instantei si
fara nicio alta formalitate prealabila, in cazul in care
Cumparatorul nu isi executa in mod corespunzator obligatiile
asumate in baza oricarui contract incheiat intre cele doua
parti, indiferent de obiectul raportului juridic.

Art. 12. The Seller shall have the right to terminate the
Contract as of full right, based on a notification, without
court intervention and any other prior formality, if the Buyer
fails to adequately perform its obligations assumed
according to any contract concluded between the two
parties, irrespective of the scope of legal relationship.

Art. 13. Valoarea creditului comercial stabilita de Vanzator

in baza Contractului, se aplica tuturor contractelor incheiate
intre cele doua parti, indiferent de obiectul raportului juridic.

Art. 13. The value of the commercial credit set out by the
Seller pursuant to the Contract shall be applied to all
Contracts concluded between the two Parties, irrespective of
the subject matter of the respective legal relationship.

Art. 14. In cazul in care, la solicitarea Cumparatorului,

transportul este asigurat de Vanzator si urmare a efectuarii
transportului se constata o diferenta intre cantitatea
facturata de Vanzator (la momentul transmiterii proprietatii
asupra produselor petroliere in depozitele Vanzatorului) si
cantitatea descarcata efectiv la Cumparator (al carei nivel
este inregistrat in tichetul tiparit de debitmetrul instalat pe

Art. 14. Should transportation, upon the Buyers request,

be provided by the Seller (according to art. 8.6 of the
Contract) and following the transport a difference should
arise between the quantity invoiced by the Seller (at the
moment of transferring the property right over the oil
products in the Sellers warehouses) and the quantity
actually unloaded by the Buyer (whose level is recorded

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cisterna auto), Cumparatorul va accepta la receptie

diferentele rezultate din modificarea volumului de carburant
in functie de factori externi (cum ar fi diferente de
temperatura si/sau consumurile tehnologice legate de
depozitare, manipulare, transport si distributie produse
petroliere).

onto the ticket printed by the flowmeter installed on the

tanker truck), the Buyer shall accept upon reception the
differences resulted from the modification of the fuel volume
due to the external factors (such as temperature differences
and / or technological losses related to storage, handling,
transportation and distribution).

In cazul in care diferenta constatata depaseste 0,2% din

volumul livrat, Vanzatorul va analiza conditiile in care au
fost livrate produsele petroliere pentru fiecare operatiune de
transport in parte. In cazul in care cantitatea transportata
este mai mica de 3000 litri, Vanzatorul va analiza conditiile
in care au fost livrate produsele petroliere pentru fiecare
operatiune de transport in parte in cazul in care diferenta
depaseste 1% din volumul livrat.

Should the difference exceed 0.2% of the delivered volume,

the Seller shall analyze the conditions under which the oil
products have been delivered for each transport. Should the
transported quantity be less than 3000 liters, the Seller
shall analyze the conditions under which the oil products
have been delivered for each transport, if the difference
exceeds 1% of the delivered volume.

Prezentul act aditional a fost incheiat astazi, ____________,

la Bucuresti, in doua exemplare originale, cate unul pentru
fiecare parte. Prezentul act aditional a fost incheiat in limba
romana si in limba engleza. In cazul in care exista
neconcordante intre versiunea in limba romana si cea in
limba engleza, versiunea in limba romana va prevala.

This Addendum was concluded this day of, __________, in

Bucharest, in two original counterparts, one for each Party.
This Addendum was concluded both in the Romanian and
English languages. In case of discrepancies between the
Romanian and the English version, the Romanian version
shall prevail.

V A N Z A T O R/SELLER,

CUMPARATOR/BUYER,

SC Rompetrol Downstream SRL

SC _____________________________

__________________/___________________

__________________/__________________

_________________/____________________

__________________/__________________

________________/_____________________

Derulant/Contract Owner
_________________________

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