Petrol Group — Governance Information 2016

Dec 16, 2016

Statement of Independence of the Member of the Supervisory Board of the _______________ Company

In accordance with point 8 of Article 17.2 of the Corporate Governance Code for Listed Companies of 8 December 2009 (hereinafter: the "Code") and in regard to my function as member of the supervisory board of the company __________________________________, I the undersigned ______________________________ hereby declare that I possess sufficient experience and knowledge for the performance of the function of supervisory board member and declare my position as to the potential conflicts of interest referred to in Appendix C of the Code.

Please, mark whether the statement is true or false. The criteria referred to in Appendix C of the Code are applied to ascertain the verity of the statement:

• a) I am not an executive or managing director of the company or an associated company, and not having been in such a position for the previous five years;
• b) I am not employed at the company or associated company and have not held such a position over the course of the past three years.

TRUE FALSE

TRUE FALSE

c) I do not receive significant additional remuneration from the company or an associated company apart from a fee received as supervisory board member.

TRUE FALSE

d) I am not and do not represent in any way the controlling shareholder(s).

TRUE FALSE

e) I do not have, or have not had within the last year, a significant business relationship with the company or an associated company, either directly or as a partner, shareholder, director, or senior employee of a body.

TRUE FALSE

f) I am not, or have not been within the last three years, partner or employee of the present or former external auditor of the company or an associated company.

TRUE FALSE

g) I am not an executive director or management board member in another company in which an executive director or management board member of the company is a supervisory board member. I also do not have other links with executive directors or management board members of the company through involvement in other companies or bodies.

TRUE FALSE

h) I have not served on the supervisory board for more than three terms (or, alternatively, more than 12 years).

TRUE FALSE

i) I am not a close family member of management board members or of persons in the situations referred to under criteria (a) through (h).

TRUE FALSE

In addition to the above,

• I am not a member of expanded management of an associated company and

	TRUE	FALSE
-	I have not taken part in the drafting of the contents of the proposed annual report of the company.
	TRUE	FALSE

___________________________________________________________________________

Conflict of interest exists when impartial and objective performance of tasks or decisionmaking of a member of the supervisory board or management board is compromised by their personal economic interest, interests of the family, its emotions, political or national sympathy/aversion, or any other associated interest with another natural person or legal entity.

Is your decision-making in accordance with the above definition affected by any other fact not mentioned above?

NO YES

Please, elaborate if your answer was YES:

______________________________________ ______________________________________

In view of the disclosed potential conflicts of interest, I declare myself to be:

Please, encircle appropriately:

a) an independent member of the supervisory board

b) a dependent member of the supervisory board.

Note: Supervisory board members are considered to be independent if they meet all independence criteria (all statements above are marked as true).

By affixing my signature, I permit the publication of the signed statement on the company's website.

Date: ______________ Signature: ___________________

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