Zentiva : Ziadost o vyplatu dividend Zentiva - ENG

THE APPLICATION FOR THE PAYOUT OF DIVIDENDS BY BANK TRANSFER (THE "APPLICATION")

(Please fill in the Application legibly in block capitals)

The below shareholder (the "Shareholder") of Zentiva, a.s., with its registered seat at Einsteinova 24, 851 01 Bratislava, Slovak Republic, company identification number (IČO): 31 411 771, registered with the Commercial register maintained by the District court Bratislava I, Section: Sa, Insert No.: 5652/B (the "Company")

hereby request the Company to pay-out the dividends approved by the general meeting of the Company, which took place on 28 June 2022, appertaining to all shares of the Shareholder in the Company, by a bank transfer to the bank account stipulated below.

I. Shareholder identification details (natural/legal person)*

Name and surname / company name:

Permanent residence / registered seat:

Personal number / company identification number (IČO) (or foreign identification number (ZIČ) registered by the Centrálny Depozitár Cenných Papierov, a.s.):

• In case this Application is submitted by a person to whom the Shareholder has transferred the right of pay-out of dividend, this Application shall be filled in by this person, who will provide its identification details. Along with this Application, the person shall also submit a contract for transfer/assignment of dividends and/or another document indicating the authorisation for the dividend payout.
  A shareholder who is a legal person with the registered seat outside the Slovak Republic shall also submit an extract from the corresponding register in which this legal person is registered. The extract shall not be older than 3 months and shall indicate the means of acting on behalf of a legal person. Alternatively, the shareholder shall submit other documents confirming that the person who signed this Application was authorized to act on behalf of a legal person.
  A shareholder who is submitting this Application through another person will also submit a written power of attorney granted by the Shareholder.

II. The bank account stipulated by the Shareholder for the payout of dividends

Bank account number (IBAN):

Bank name:

S.W.I.F.T. / BIC code (only necessary if the bank account is held with a bank that does not have its registered seat or a branch inthe Slovak Republic):

III. Payout of dividends for previous time periods

If the dividends of the Shareholder for previous time periods are not paid out, the Shareholder is, by this Application, entitled also to request the pay-out of these dividends, by indicating the year (years), for which the Shareholder requires the payout of dividends. In such case, the Company will assess the eventual entitlement of the Shareholder to the payout of dividends and shall pay out the relevant dividends for the corresponding years to the bank account stipulated above.

I hereby request the payout of dividends also for the year (years): ..............................................................

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IV. The declaration on tax residence

The Shareholder shall tick one of the options listed below (i.e. one of the options from a) to f)) as a sign of declaration of their tax residence in line with the act no. 595/2003 Coll. on income tax, as amended (the "Income Tax Act") and, if appropriate, the Shareholder shall fill in the other required details. The Shareholder acknowledges that without filling in the details below, the Company will not be able to properly process this Application and pay out the dividends to the Shareholder as the Company will not be able to properly fulfil its obligations in relation to the pay-out of dividends in line with the Income Tax Act, or, rather, that the Company shall have to deduct withholding tax from dividends paid out to shareholders who are residents of an uncooperating state, in the maximum amount, i.e. 35%. A Shareholder who is not a tax resident of Slovak republic (that is, typically, persons who do not have their permanent residence or their registered seat in Slovak republic) also acknowledges that the Company may require them to submit the certificate of tax residence issued by the tax administrator of the given country, in which the Shareholder is a tax resident. Such a certificate may be used for the purposes of assessment of the appropriate level of the withholding tax imposed on the dividends, as well as in the case of an inspection conducted by the tax administrator regarding settlement and deduction of the withholding tax from the dividends.

a) Natural person - tax resident of the Slovak Republic

b) Natural person - tax resident of a cooperating state

- cooperating state*: ...........................................................................

• will require a confirmation of tax payment (yes/no)**:
• date of birth**: ..................................................................................................

c) Natural person - tax resident of a non-cooperating state

• I will require a confirmation of tax payment (yes/no)**:
• date of birth: ......................................................................................................

d) legal person - tax resident of the Slovak Republic

e) legal person - tax resident of a cooperating state

f) legal person - tax resident of a non-cooperating state

• • I will require a confirmation of tax payment (yes/no)**: .................
  • identification number assigned abroad**: ........................................
• The Shareholder who is not a tax resident of the Slovak Republic and is a natural person - resident of a cooperating state (e.g. Czech Republic) shall also indicate the corresponding country of which the Shareholder is a tax resident of for the purposes of assessment of the applicable tax in line with the corresponding international treaty.
• The Shareholder who is not a tax resident of the Slovak Republic shall indicate whether the Shareholder will require a confirmation of the tax payment from the corresponding tax administrator. In case such a Shareholder will require the confirmation, the Shareholder shall also indicate the date of birth (in case of a natural person), or the identification number assigned abroad (in case of a legal person).

A cooperating state is a state with which the Slovak Republic has concluded an international treaty on preventing double taxation or on exchange of information regarding taxes; or states that are Contracting States to the international treaty containing provisions on exchange of information for the tax purposes to a similar extent. The list of the cooperating states, in line with § 2 part x) of the Law on Income Tax, is published on the website of the Ministry of Finance of the Slovak Republic.

By signing this Application below, the Shareholder confirms (i) the accuracy and completeness of the details provided to the Company in this Application at the date of signing this Application and (ii) that the Shareholder is the final recipient of the dividend paid out under this Application. The Shareholder acknowledges that the Company will use these details for the purposes of paying out the dividends and for the purposes of deduction of the withholding tax from dividends in line with the applicable legal regulations and their payment and report to the corresponding tax administrator, or for the purposes fulfilling of other statutory obligations regarding the payout of dividends.

		The Shareholder: in ..................................	on (date) .................................. .
		(in the case of a legal person, or in the case of a substitute, the personal details of the signatory
		will be provided)
		Name:..................................................................
		Position:		.................................Signature:
		The contact details of the Shareholder:

Providing the contact details is voluntary and, in the case they are provided, they might be used by the Company for the purposes of simplifying the communication with the Shareholder during processing of this Application, for example in case of imperfect or illegible completion of the Application. The Shareholder, by filling in these details, consents to their processing by the Company. The Shareholder can revoke the consent by sending a revocation of consent to the Company in the same manner as they granted the consent.

..................................................................................email:	phone: ................................................................

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