Statutory Declaration of producer of audiovisual fixation

Business name: …………………………………………………………………………………

Residence: ………………………………………………………..…………………………….

Identification/Registration No. :……………………………………………. …………………

Bank account (Bank address, IBAN).:……………………………... …………………………

Email: …………………………………………………………………………………………..

I declare, that above mentioned producer, is authorized under the Art. 80 paragraph (2) e) and paragraph (3) of Law No. 121/2000 Coll. as amended by after regulations to claim remuneration according to the Art. 22, 23 and 25 of the same Law collected by Intergram under the Art. 96 of the same Law for the year 2012.

I declare that during the period from 1.1. 2012 till 31.12.2012 were below mentioned audiovisual works :

- terrestrially broadcasted by nationwide television

- sold on mediums in Czech Republic or

- presented in cinemas in Czech Republic

and I accord following datas conclusive for fixing the remuneration.

Name of Audiovisual work / share 1) / Broadcasted length 2) / Sale of mediums 3) / Attendance in cinemas4) / Notes to Audiovisual work

1)  By the audiovisual works, which originated based on collaboration agreements, please file the share on right holding (in %) according to the § 25 (Right to remuneration in connection with the reproduction of the work for personal use)

2)  Please file the total length (in minutes) of individual audiovisual works terrestrially broadcasted by nationwide television (notalivebroadcast), i.e. ČT1, ČT2, ČT24, ČT 4, NOVA, Nova Cinema, Prima Family, Prima Cool, Prima Love, TV Barrandov.

3)  File the amount of income associated with a sale of mediums of audio-visual records, distributed for purpose of individual sale or with direct retail sale to final consumers in the territory of the Czech Republic. The amount of income is real sale price of mediums without VAT.

4)  File the attendance (number of attendants) of individual audio-visual records in cinemas in the territory of the Czech Republic

I agree that rightness of all datas filed in this Statutory Declaration can be checked by worker of Intergram in original documents.

Date: Signature according to the registered model of signature

form of company:

Annex - Statutory Declaration of producer of audiovisual fixation

Name of Audiovisual work / share 1) / Broadcasted length 2) / Sale of mediums 3) / Attendance in cinemas4) / Notes to Audiovisual work

1)  By the audiovisual works, which originated based on collaboration agreements, please file the share on right holding (in %) according to the § 25 (Right to remuneration in connection with the reproduction of the work for personal use)

2)  Please file the total length (in minutes) of individual audiovisual works terrestrially broadcasted by nationwide television (notalivebroadcast), i.e. ČT1, ČT2, ČT24, ČT 4, NOVA, Nova Cinema, Prima Family, Prima Cool, Prima Love, TV Barrandov.

3)  File the amount of income associated with a sale of mediums of audio-visual records, distributed for purpose of individual sale or with direct retail sale to final consumers in the territory of the Czech Republic. The amount of income is real sale price of mediums without VAT.

4)  File the attendance (number of attendants) of individual audio-visual records in cinemas in the territory of the Czech Republic.