NAME : INCOME TAX - INDIVIDUAL

CPF¹: FISCAL YEAR:

ANNUAL INCOME TAX RETURN CALENDAR YEAR:

SUMMARY -----------------------------------------------------------------(Amounts in R$²)

TAXABLE INCOME
Received from juridical persons by the holder
Received from juridical persons by the holder’s dependents 0
Received from individuals to the holder 0
Received from individuals to the holder’s dependents 0
Received from abroad 0
Taxable final income from rural activities 0
TOTAL

DEDUCTIONS
Contributions to the official retirement fund
Contributions to private retirement funds and FAPI³
Dependents
Educations tuitions fees
Medical expenses
Alimony 0
Cash register book 0
Total

TAX DUE TAX TO BE REFUNDED 0

Calculation basis BALANCE OF TAX TO BE PAID
Tax
Incentive deductions 0
Tax due I
Contribution to official pensions fund for domestic 0 PAYMENTS IN INSTALMENTS
employees
Tax due II Instalment amount
TAX PAID Number of instalments
Holder’s income tax withheld at source BANK INFORMATION
Holder’s dependents income tax withheld at source 0 Bank
Monthly mandatory tax payment 0 Agency
Tax on extra personal income tax 0 Debit account
Tax paid abroad 0
Income tax withheld (Operation at the Stock 0 TAX TO BE PAID
Exchange – Law n° 11033 of 2004)
TOTAL Capital gains – Currency in kind
EQUITY EVOLUTION
Assets and rights on Dec 31, 2018
Assets and rights on Dec 31, 2018
Actual debts and encumbrances on Dec 31, 2018 0
Actual debts and encumbrances on Dec 31, 2018
Spouse’s information 0

OTHER INFORMATION
Exempt and no-taxable income
Income subject exclusively to taxation at the source/income subject to conclusive taxation
Tax paid on Capital Gains 0
Tax paid in Foreign Currency – Assets, rights, finance investments 0
Total of income tax withheld (Operation at the Stock Exchange – Law n° 11033 of 2004), according to 0
information supplied by the holder
Tax paid on variable income 0
Donations to Political Parties, Financial Committees and Candidates 0

¹Brazilian individual tax payer registry

²Currency rate used: 1 US$/R$ (4.17)
³Planed or programmed individual retirement fund