Latvijas Gaze — Proxy Solicitation & Information Statement 2016

Nov 16, 2016

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author: "Vinsents_Makaris"
date: 2016-11-10 06:00:00+00:00
processor: python-docx+mammoth
status: success

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Shareholder’s Data Sheet

The form should be mailed to: JSC "Latvijas Gāze", Vagonu street 20, LV-1009, LATVIA.

The form may be also e-mailed in electronic form to info@akcionari.lg.lv. The form can be retrieved electronically from www.lg.lv, under Company Reorganisation.

I SHAREHOLDER’S INFORMATION

Natural persons Given name: ___________________________________________________ Surname: ___________________________________________________ Personal ID No.: ___________________________________________________ *Country of residence: ___________________________________________________ Non-residents DOB (yyyy.mm.dd): ___________________________________________________
Legal persons Company’s name: ___________________________________________________ Registration No: ___________________________________________________ *Country of residence: ___________________________________________________

* Taxpayer’s country of residence in the meaning of Section 14 of the Law on Taxes and Fees.

II SETTLEMENT INFORMATION

Account in Latvia Account No. (IBAN): ___________________________________________________ Non-Latvian account Account No. (IBAN): ___________________________________________________ Bank’s SWIFT code: ___________________________________________________ Bank’s name: ___________________________________________________ Corresponding account (if applicable) Account No. (IBAN): ___________________________________________________ Bank’s SWIFT code: ___________________________________________________ Bank’s name: ___________________________________________________

III CONTACT INFORMATION

You are requested to update the information if the address of residence, phone number or e-mail address has changed since submitting the subscription for shares: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________