DV-05 Form

POWER OF ATTORNEY[1]

________________________________________________________________________________

Place of issue of the power of attorney, date of issue (specified in words)

I, ______________________________________________________________________________

(last, first and patronymic name)

________________________________________________________________________________

(identification document: name, series, number, issued on and issued by)

________________________________________________________________________________

(residing at, date of birth, place of birth)

do hereby authorize

________________________________________________________________________________

(last name, first name and patronymic of the authorized officer)

________________________________________________________________________________

(identification document: name, series, number, issued on and issued by)

________________________________________________________________________________

(residing at, date of birth, place of birth)

to undertake the following actions[2] on my behalf at the Bank GPB (JSC) depository:

  1. Initiate any transactions in compliance with the depository service terms and conditions that are in effect at Bank GPB (JSC), including changes in the details provided in the questionnaire and bank details as well as transactions with foreign financial instruments not qualified as securities.
  2. Initiate:  

instructions to open and close securities accounts, subaccounts of the securities accounts;

instructions to change the securities account details, details provided in the questionnaire and banking details;

instructions to carry out transactions to accept securities for custody and (or) record keeping;

instructions to carry out transactions to withdraw securities from custody and (or) record keeping;

instructions to transfer securities;

instructions to register the pledge of securities, including subsequent pledge; transfer pledged securities, terminate the pledge;

instructions to receive securities account statements and certificates;

_______________________________________________________________________

(list any other transactions)

  1. Pay for the services and effect other settlements to undertake the actions specified above.
  2. Receive and transfer any communications, documents and reports associated with securities account services and execution of any depository transactions as well as dealing with foreign financial instruments not qualified as securities.
  3. Provide for me and on my behalf a consent to submit my details to foreign tax authorities, including the U.S. Internal Revenue Service (IRS) and state authorities of the Russian Federation (including the Central Bank of Russia, a federal executive body authorized to undertake actions to combat money laundering and terrorism financing, a federal executive body authorized to control and monitor taxes and levies), fill in and sign any self-certification forms, submit any information and provide comments for the purposes of compliance with the foreign account tax law of foreign states.[3]

This Power of Attorney is valid till ______________20__  without the right of substitution.

/__________________/_____________________________________________________________

Signature                                 Last, first and patronymic name

This Power of Attorney is drafted and signed in my presence[4]

                          (position and division, last, first and patronymic name, signature of an employee of Bank GPB (JSC))

[1] Individuals shall execute a power of attorney in their own handwriting at the premises of Bank GPB (JSC) in the presence of a Bank employee or get the power of attorney certified by the notary public.

[2] The scope of the granted authorities is defined by the Customer at its sole discretion in compliance with the list provided in the power of attorney

[3] Item 5 shall be selected only if the Depositor is a tax resident of the USA.

[4] Specified when the signature of the Customer’s representative is certified by an employee of Bank GPB (JSC)