AB "Kauno energija"

Address: Raudondvario pl. 84, 47179 Kaunas, Lithuania Code: 235014830; VAT code: LT 3501483014 Date is collected and stored in the Register of Legal Entities

The shareholder (nature person) name, the shareholder (legal person) title:

The shareholder (nature person) the personal code, name, the shareholder (legal person) code:

The numbers of share:

Please underline the option you choose in the table "YES" or "NO"

No.	The items of the agenda	The draft of the decisions		Shareholder's agenda
1.	Regarding Kauno Energija AB permission for Gazprom AB to transfer shares of Kauno Termofikacijos Elektrinė UAB and to exempt from obligations terms of undertakings agreement.	1. To confirm terms of permission for Gazprom AB to transfer shares of Kauno Termofikacijos Elektrinė UAB and of exemption from obligations terms of undertakings agreement. 2. To oblige the Management Board of Kauno Energija AB to present for confirmation to the Extraordinary General Meeting of Shareholders of Kauno Energija AB the final agreement regarding permission for Gazprom AB to sell shares of Kauno Termofikacijos	"YES"	"NO"

	Elektrinė UAB and to exempt from obligations under undertakings agreement when such will be reached.

$(\text{date})$	(shareholder for any other person entitled to vote his schares), the name, signature, legal person seal




























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