[PLEASE FILL IN the CONTRACTOR’S HEADER ]

Statement regarding the condition of the goods delivered

under Contract no [PLEASE INSERT]

Date: [insert the day, month, year]

I, the undersigned, authorized representative of [PLEASE FILL IN THE CONTRACTOR’S NAME AND ID],
hereby declares, under the sanction to be applied for false declarations in public documents, the following:

All goods delivered to OMV Petrom under the contract of purchase NR [PLEASE FILL IN] have not
been previously used, being completely new.

I, the undersigned, hereby declare that I have taken note of the provisions of art. 326 "false in statements" of the
Criminal Code relating to "Incorrect declaration of the truth, made to an organ or to a state institution or anoher
unit of the referred to in article 175, in order to produce legal consequences for himself or for another when,
according to the law or circumstances, the statement made serves to produce those consequences, can be
punished with imprisonment from 3 months to 2 years or with fine. "

Signature
[person or persons authorized to sign on behalf of Contractor]