1.1. Name and UIC of the Company That Applies for Alicence

QUESTIONNAIRE - DECLARATION

ABOUT QUALIFICATIONS, WORK EXPERIENCE AND GOOD REPUTATION UNDER ARTICLE 5, PAR. 1, P. 2 OF BNB ORDINANCENo. 16

1. General data

1.1. Name and UIC of the company that applies for alicence:

______

1.2. Name and UIC of the branch/agent of the person under p. 1.1 or of alicensedpayment institution or electronic money institution;name and UIC of the licensedpayment institution or electronic money institution, respectively:

______

(onlywhen completedbythe persons who run and represent branches or agentsofthe company under p. 1.1 or of alicensedpayment institution or electronic money institution)

1.3. Position of the person who runs and representsthe company under p. 1.1 (or the branch/agent of the person under p. 1.2): ______

1.4. Datefrom which this position is held: ______

1.5. Responsibilities, duties and powers related to this position:

______

2. Personal data of the person who runs and represents, or who is a member of a management or supervisory body of, the company under p. 1.1 (personal data of the person who runs and represents the branch/agent under p. 1.2, respectively)

2.1. Full name: ______

2.2. Date and place of birth:______

2.3. Unified identification number/foreigner’s personal ID number:______

2.4. Nationality: ______

2.5. Gender: ______

2.6. Permanent address: ______

2.7. Present address if different from the permanent address: ______

2.8. Telephone: ______

2.9. E-mail: ______

2.10. Has your name been changed?

Yes / No

(If yes, please complete the informationin points 2.10.1 - 2.10.3)

2.10.1. Previous name: ______

2.10.2. Date of the name change(dd/mm/yyyy): ______

2.10.3. Reason for the name change: ______

3. Education and professional qualifications

3.1. Education

3.1.1. Type of education degree(Please indicate the degrees earned and the field/discipline of degree.): ______

______

3.1.2. Educational institution;the year in which the degree was earned:

______

3.2. Languages:

Language / Level of command of the language (level according to the Common European Framework of Reference for Languages)

(Please add lines for more languages.)

3.3. Professional qualifications

3.3.1. Title of qualification awarded;date of issue;awarding organisation:

______

3.3.2. Title of qualification awarded;date of issue;awarding organisation:

______

(Please continue the list for additional information.)

4. Work experience

4.1. Employer: ______

4.1.1. Position held:______

4.1.2. Period(dd/mm/yyyy)

From / To

4.1.3. Address, telephone and e-mail of employer:

______

4.2. Employer: ______

______

4.2.1. Position held: ______

4.2.2. Period(dd/mm/yyyy)

From / To

4.2.3. Address, telephone and e-mail of employer: ______

______

5. Information on the companies in which the person who runs and represents, or whoisa member of a management or supervisory body of, the company under p. 1.1 (the person who runs and represents the branch/agent under p. 1.2, respectively), has/had in the last 5 yearsa qualifying holdingin the capital

5.1.1 Name and UIC of the company, its registered office and head office address:

______

5.1.2. Percentage of equity participation, number of shares/stocks, and total nominal value in BGN)

Share (%) / Number of shares/stocks / Total nominal value(in BGN)

5.1.3. Date of acquiring the equity participation (dd/mm/yyyy): ______

5.1.4. Date of change(dd/mm/yyyy): ______

5.1.5. Has a forced collection action been taken against the company?

Yes / No

(If yes, please indicate the type and amount of the obligation; the reasons for the forced collection action and how it ended.)

______

5.1.6. Has any foreclosure, distraint or other enforcement methods been applied to the company?

Yes / No

(If yes, please indicate the enforcement method and for what obligations.)

______

5.1.7. Has the company been wound up because of insolvency or is it now going through bankruptcy proceedings?

Yes / No

(If yes, please indicate the number and date of the decision for ending the bankruptcy proceedings and deregistration of the company, and the number and date of the decision for initiation of the bankruptcy proceedings.)

______

5.2.1 Name and UIC of the company, its registered office and head office address:

______

5.2.2. Percentage of equity participation, number of shares/stocks, and total nominal value in BGN)

Share (%) / Number of shares/stocks / Total nominal value(in BGN)

5.2.3. Date of acquiring the equity participation(dd/mm/yyyy): ______

5.2.4. Date of change(dd/mm/yyyy): ______

5.2.5. Has a forced collection action been taken against the company?

Yes / No

(If yes, please indicate the type and amount of the obligation; the reasons for the forced collection action and how it ended.)

______

5.2.6. Has any foreclosure, distraint or other enforcement methods been applied to the company?

Yes / No

(If yes, please indicate the enforcement method and the obligations.)

______

5.2.7. Has the company been wound up because of insolvency or is it now going through bankruptcy proceedings?

Yes / No

(If yes, please indicate the number and date of the decision for ending the bankruptcy proceedings and deregistration of the company, and the number and date of the decision for commencing the bankruptcy proceedings.)

______

6. Information on companies, whichthe person who runs and represents,or who isa member of a management or supervisory body of,the company under p. 1.1 (the person who runs and represents the branch/agent under p. 1.2, respectively) controls/controlled inthe last 5 years

6.1.Name of the company, its registered office and head office address, UIC:

______

6.2.In what way is the companycontrolled?

______

6.3.When did you start to exercise control?(dd/mm/yyyy): ______

6.4. Date of change(dd/mm/yyyy): ______

6.5. Has a forced collection action been taken against the company?

Yes / No

(If yes, please indicate the type and amount of the obligation; the reasons for the forced collection action and how it ended.)

______

6.6. Has any foreclosure, distraint or other enforcement methods been applied to the company?

Yes / No

(If yes, please indicate the enforcement method and the obligations.)

______

6.7. Has the company been wound up because of insolvency or is it now going through bankruptcy proceedings?

Yes / No

______

7. Informationon thefinancial discipline/correctnessofthe person who runs and represents,or who is a member of a management or supervisory body of,the company under p. 1.1 (the person who runs and represents the branch/agent under p. 1.2, respectively)

7.1. Have you had any past-due obligations?

Yes / No

(If yes, please indicate the type and amount of these obligations, and to whom you owe/owed them (government, municipality, bank, third parties).)

______

7.2. How did you pay off your obligations under p. 7.1?

______

7.3. Has a forced collection action been taken against you?

Yes / No

(If yes, please indicate the type and amount of the obligation; the reasons for the forced collection action and how it ended.)

______

7.4. Have any administrative sanctions been imposed on you for violation of tax laws?

Yes / No

(If yes, please indicate the grounds for and the type of administrative sanction imposed.)

______

7.5. At present are there any administrative penal proceedings initiated against you for violation of tax laws?

Yes / No

(If yes, please indicate the violation because of which the administrativepenal proceedingshave been initiated, andat what stage the proceedings are now.)

______

7.6. Please indicate the amount of income tax paid by you as a natural person over the last 2 years:

Year / Amount (in BGN ‘000)

8. Informationonthe financial discipline/correctnessofthe company under p. 1.1 (or the branch/agent under p. 1.2)

8.1. Has the companyhad any past-dueobligations?

Yes / No

(If yes, please indicate the type and amount of these obligations, and to whom the company owes/owed them (government, municipality, bank, third parties).)

______

8.2. How did the company pay off its obligations under p. 8.1?

______

8.3. Has a forced collection action been taken against the company?

Yes / No

(If yes, please indicate the type and amount of the obligation; the reasons for the forced collection action and how it ended.)

______

8.4. Have any administrative sanctions been imposed on the company for violation of tax laws?

Yes / No

(If yes, please indicate the grounds for and the type of administrative sanction.)

______

8.5. At present are there any administrative penal proceedings initiated against the company for violation of tax laws?

Yes / No

(If yes, please indicate the violation because of which the administrative penal proceedings have been initiated, and at what stage the proceedings are now.)

_______

9. Relations with competent authorities

9.1. Have any administrative sanctions or administrative enforcement actionsfor violation of laws and regulations applicable to the business of companies in the banking or financial sector, banklike institutions or banklike companies, been imposed on you or on a company: 1) in which you held a management position(‘Managementposition’ within the meaning of § 1 (1) of the Additional Provisions of Ordinance No. 20 of 28 April 2009 ontheIssuanceofApprovalstotheMembersoftheManagementBoard (BoardofDirectors) andSupervisoryBoardof a CreditInstitutionandRequirementsforPerformingtheirDuties); 2) which you control or controlled; 3) in which you have or had a qualifying holding?

Yes / No

(If yes, please indicate the name and UIC of the company; the position held;how control is/was exercised;the percentage of qualifying holding; the legal provisions that have been violated; the date and number of the act on the imposed sanction or measureand the issuing body.)

______

9.2. Do you know of any pending proceedings for imposing administrative sanctions or administrative enforcement actions under p. 9.1?

Yes / No

(If yes, please indicate the name and UIC of the company; the position held; how control is/was exercised;the percentage of qualifying holding; the legal provisions that have been violated; the starting date of the proceedings; the body that initiated the proceedings.)

______

9.3. Have you been dismissed, due to an applied administrative enforcement action,froma management positionin a company in the banking or financial sector, a banklike institution or a banklike company?

Yes / No

(If yes, please indicate the name and UIC of the company;the position held; the reason for dismissal; the date and number of the act on the dismissal and the issuing body.)

______

9.4. Has a licence for activity that needs to be licensed by the Bulgarian National Bank, ortheFinancial Supervision Commission, or a relevant competent authority in another country, been refused to a company: 1) in which you held a management position; 2) which you control or controlled; 3) in which you have or had a qualifying holding?

Yes / No

(If yes, please indicate what the licence is for; the competent authority that refused the licence; the name and UIC of the company; the position held;how control is/was exercised;the percentage of qualifying holding; the reason for the refusal; the number and dateof the act whereby the licence was refused.)

______

9.5. Has a licence been withdrawn from, or has a procedure for withdrawing a licence been initiated against, a company: 1) in which you held a management position; 2) which you control or controlled; 3) in which you have or had a qualifying holding?

Yes / No

(If yes, please indicate what the licence was for;the competent authoritythat withdrew the licence; the name and UIC of the company; the position held;how control is/was exercised;the percentage of qualifying holding; the reason for the licence withdrawal; the number and dateof the act on the licence withdrawal.)

______

9.6. Has registration been refused to, or has deregistration been made of, a company carrying out activity that is subject to registration by the Bulgarian National Bank, or theFinancial Supervision Commission, or a relevant competent authority in another country,of you as a natural person or of a company: 1) in which you held a management position; 2) which you control or controlled; 3) in which you have or had a qualifying holding?

Yes / No

(If yes, please indicate the object of registration;the competent authority that refused to make the registration or has made the deregistration; the reason for the refusal or for deregistration; the number and dateof the act; the name and UIC of the company; the position held;how control is/was exercised;the percentage of qualifying holding.)

______

9.7.Has a registration, membership or issuance of a permit or licence forpursuing tradingactivities, business activities or practicing a profession been refused to you as a physical person or to a company: 1) in which you held a management position; 2) which you control or controlled; 3) in which you have or had a qualifying holding?

Yes / No

(If yes, please indicate the subject of the registration, permit, membership, licence, the competent authority that refused the registration, permit, membership orlicence, the grounds for refusal; the number and date of the act, respectively;the name and UIC of the company; the position held;how control is/was exercised; the percentage of qualifying holding.)

______

9.8. Has a licence been withdrawn from, or has a registration, permit or membership for pursuing tradingactivities, business activities or practicing a profession been terminated to you as a physical person or to a company:1) in which you held a management position; 2) which you control or controlled; 3) in which you have or had a qualifying holding?

Yes / No

(If yes, please indicate the subject of the registration, permit, membership, licence, the competent authority that has withdrawn license, terminated the registration, permit, membership orlicence, the grounds for withdrawal of the license, termination of the registration, permit, membership, the number and date of the act, respectively;the name and UIC of the company; the position held;how control is/was exercised; the percentage of qualifying holding).

______

9.9. Have you been discharged from a body or entity from the public sector, financial services sector, or a professional body or industry association?

Yes / No

(If yes, please indicate the name and UIC of the company; the position held; number and date of the decision by which you were discharged from a body or entity from the public sector, financial services sector, or a professional body or industry association).

______

9.10 Have you held a management position or been an unlimited liability partner in a company wound up due to bankruptcy or in a company that is going throughbankruptcy proceedings?

Yes / No

(If yes, please indicate the name and UIC of the company; the position held;the number and date of the decision whereby the bankruptcy was announced; the number and date of the decision for initiation ofthe bankruptcy proceedings.)

______

9.11. Has a company been wound up with acourt decision: 1) in which company you held a management position; 2) which you controlled; 3) in which you had a qualifying holding?

Yes / No

(If yes, please indicate the name and UIC of the company; the position held; the number and date of the decision for winding up the company’s business.)

______

9.12. Have your qualifications, work experience and reputation (fitness and propriety) been assessed by the Bulgarian National Bank, ortheFinancial Supervision Commission, or a relevant competent authority in another countrywith regard to holding a management position or acquiring a shareholding?

Yes / No

(If yes, please indicate the assessing body; the reason for the assessment and its result.)

______

9.13. Have you been denied permission to hold amanagement position or to acquire ashareholdingbythe Bulgarian National Bank, ortheFinancial Supervision Commission, or a relevant competent authority in another country?

Yes / No

(If yes, please indicate the body that denied permission to you and why.)

______

10. Additional information

10.1. Do you have any financial obligationstothe company under p. 1.1 (or the branch/agent under p. 1.2)?

Yes / No

(If yes, please indicate the type and amount of these obligations.)

______

10.2. Have any disciplinary sanctions been imposed on youforviolationof the labour law?

Yes / No

(If yes, please indicate the employer’s name; the reason for the disciplinary sanction and its type.)

______

10.3. Have you been dismissed froma management position in cases other than those under p. 10.2?

Yes / No

(If yes, please indicate the reasons for the dismissal.)

______

10.4. Do you know of any pendingcriminal proceedings against youfor an indictable offence?

Yes / No

(If yes, please indicate the legalqualificationof the offence, the datewhen the proceedings were initiated and where.)

______

10.5. Have you been given a modified audit opinion (a qualified opinion or a disclaimer of opinion, respectively) after an audit in a company: 1) in which you held a management position; 2) which you controlled; 3) in which you had a qualifying holding?

Yes / No

(If yes, please indicate the name and UIC of the company;the position held;how control is/was exercised;the percentage of qualifying holding;the reasons for the modified audit opinion.)

______

10.6. Please provide any other information that you consider relevant:

______

I hereby declare that:

1. I give my explicit consent for the BNB to process the data and information contained in this questionnaire.

2. The statements and information given in this questionnaire-declarationare truthful and accurate and I do not know about any other informationthat could affect the declaredcircumstances.

3. I undertake to inform the BNB about any change in the declared circumstancesunder Art. 3, par. 8ofBNB Ordinance No. 16 on the issuance of licences and authorisations, on the registration under Article 19 of the Law on Payment Services and Payment Systems, and on the requirements for the business activities of operators of payment systems providing settlement finality.

4. I am aware of the liability for having provided untruthful information.

The Bulgarian National Bank is a personal data administrator. The personal data voluntarily provided by you are collected and processed for identification purposes and for the purposes of BNB Ordinance No. 16 on the issuance of licences and authorisations, on the registration under Article 19 of the Law on Payment Services and Payment Systems, and on the requirements for the business activities of operators of payment systems providing settlement finality. Third persons may obtain information only as provided by law. You have the right to access and correct your personal data provided to us.

Date(dd/mm/yyyy):______Signature: ______