STATEMENT
on the meeting of independence criteria by a Supervisory Board member
of the State Specialized Forest Enterprise “Forests of Ukraine” 
(hereinafter - the Enterprise)

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

hereby inform that I meet the independence criteria put forward to a member of the Supervisory Board in accordance with Article 113 of the Law of Ukraine “On State Property Management”:
1)	I am not and within the last five years have not been an official of the Enterprise, subsidiary, branch, representation, and/or other separate unit, except as an independent member of the supervisory board;
2)	I am not and within the last three years have not been an employee of the Enterprise, subsidiary, branch, representation, and/or other separate unit; 
3)	I am not an affiliated person (as defined in the Law of Ukraine “On Joint-Stock Companies”) of Enterprise, subsidiary, branch, representation, and/or other separate units and/or their officials;
4)	I am not receiving and within the last three years have not received any income from the Enterprise, subsidiary, branch, representation, and/or other separate unit, except for income as a supervisory board member; 
5)	I do not hold (directly or indirectly) 5% and more of the statutory capital of the Enterprise (independently or together with affiliated persons) and do not represent the interests of such holder;
6)	I am not a civil servant or representative of the state;
7)	I am not an independent auditor of the Enterprise, subsidiary, branch, representation, and/or other separate unit and have not held such position in the last three years preceding the appointment (election) to the supervisory board;
8)	I do not participate in audits of the Enterprise, subsidiary, branch, representation, and/or other separate unit as an auditor working for an audit organization, and have not participated in such audits in the last three years preceding the appointment (election) to the supervisory board;
9)	I do not have and have not had within the last year substantial business relationship with the Enterprise, subsidiary, branch, representation, and/or other separate unit directly as an individual entrepreneur or as a shareholder (participant), leader or member of the executive body of an economic entity that has or had such relations. For the purposes of this paragraph, substantial business relations are determined by the Charter or the Regulation on the supervisory board;
10)	I have not been for more than 12 years totally a member of the Supervisory Board of the Enterprise;  
11)	I am not a close person to individuals mentioned in points 1-10 above (the term “close person” is used as defined in the Law of Ukraine “On Prevention of Corruption”).
The requirements of paragraphs 1, 2 and 4 of this section shall not apply to the cases of holding the position of an independent director of the company and the relations related thereto.

_____ _____________ 20____			     __________________
                                                                                                                  (signature)