STATEMENT
on the meeting of independence criteria by a Supervisory Board member
of the Gas Transmission System Operator of Ukraine LLC 
(hereinafter - the Company)

I, ____________________________________________________________________
(surname, name, patronymic)
(born on ____ ____________ 19__, passport series ____ No. ____________,                              issued  ___________________by _____________________________________________), 

hereby inform that I meet the independence criteria put forward to a member of the Supervisory Board as established by legislation of Ukraine, namely:

1.	In accordance with Article 73 of the Law of Ukraine “On Joint Stock Companies”:
-	I am not and in the past five years have not been a member of executive body of the Company and/or its affiliated legal entities;
-	I am not receiving and in the past three years have not received from the Company and/or its affiliated legal entities additional material remuneration exceeding 5% of annual income of such an entity for each of these years;
-	I do not hold (directly or indirectly) 5% and more of corporate rights of a company or I am not either a manager or a member of executive body of such a company which or an individual entrepreneur who in the past year has had substantial business relationship with the Company and/or its affiliated legal entities;
-	I am not and/or have not been in the previous three years a key partner, official or employee of an auditing entity that participated in the provision of mandatory audit services of the Company's financial statements and/or its affiliated legal entities;
-	I am not and in the past three years have not been an employee of an audit firm which has provided audit services to the Company and/or its affiliated legal entities in the past three years;
-	I am not an employee of the Company and/or its affiliated legal entities and have not been one in the past three years;    
-	I am not a shareholder – owner of controlling interest and/or I am not a representative of a shareholder – owner of controlling interest of the Company in any civil relationship;
-	I have not been for more than 12 years on aggregate a member of the Supervisory Board of the Company; 
-	I am not related to family relations with the persons specified in points 1 – 8 of part one of Article 73 of the Law of Ukraine “On Joint Stock Companies”.  

2. In accordance with Article 113 of the Law of Ukraine “On State Property Management”:
-	I am not and in the past five years have not been an officer of the Company or its subsidiary, branch, representative office and/or other separate division;
-	I am not and in the past three years have not been an employee of the Company or its subsidiary, branch, representative office and/or other separate division;
-	I am not an affiliated person (within the meaning of the Law of Ukraine “On Joint Stock Companies”) of the Company and/or its shareholders (participants), or of its subsidiary, branch, representative office and/or other separate divisions and/or officers;
-	I am not receiving and have not received any income from the Company or its subsidiary, branch, representative office and/or other separate division, except for the income in the form of remuneration for the fulfillment of the functions of a Supervisory Board member;
-	I do not hold any corporate rights in the Company (independently or together with affiliated persons) and do not represent the interests of such holder;
-	I am not a government official or a representative of the government;
-	I am not an auditor of the Company and have not been one over a certain period in the past three years preceding my appointment (election) to the Supervisory Board;
-	I do not participate in the auditing of the Company or its subsidiary, branch, representative office and/or other separate division as an auditor employed by an audit firm; neither have I participated in such auditing over a certain period in the past three years preceding my appointment (election) to the Supervisory Board;
-	I have not had in the past year any business or civil relations with the Company or its subsidiary, branch, representative office and/or other separate division either directly or as a shareholder (participant), manager or member of an executive body of the economic entity that has had such relations;
-	I have not worked in the position of an independent member of the Supervisory Board of the Company in the past three terms;
-	I am not a close person to the persons specified in the present paragraph (the term “close person” has the meaning provided to it by the Law of Ukraine “On Prevention of Corruption”).

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                                                                                                                  (signature)