Annual report 2020 prepared in the context of the obligations required of all holders of an electricity-supply licence (AGW 21.3.2002, Art.17) and/or

a gas-supply licence (AGW 16.10.2003, Art.17)

Form to be sent with its relevant appendices no later than 30 June 2021 to CWaPE,

route de Louvain-la-Neuve 4 bte 12, 5001 BELGRADE

Contact person: Stéphane Marchand, 081 32 50 16, licence@cwape.be

Identity of the case manager

First name, surname : Please mention first name and surname of the person handling this form

Function : Please indicate his role within the organisation

E-mail : Please mention his email

Phone : Please mention his phone number

Statement

I, the undersigned, Please indicate your surname and first name, Please indicate your role within your company, authorised to represent Please indicate the full name of your company,

hereinafter the company,

holder of the following licence (s):

general	☐ for all end customers	☐ electricity ☐ gas
limited	☐ to capped power (≤ 10 MW) OR a capped energy quantity (≤ 25 GWh/year)	☐ electricity ☐ gas
☐ to specific customers (≤ 10 customers)	☐ electricity ☐ gas
☐ to guaranteeing your own supply	☐ electricity ☐ gas

hereby certify that:

the company, , since 31 December 2019, one or more changes to its articles of association;

the company, , since 31 December 2019, one or more changes concerning control, a merger or a split; Initials

as of 31 December 2019, the company's head office was located at the following address:

Please indicate the full address of the head office on 31.12.2019 ;

As of 31 December 2020, the company's head office

The head office is now located at the following address:

Only to be completed if you indicated a change to the head office address

at present, the company is not in one of the situations set out in Article 4 of the AGW of 21 March 2002 and 16 October 2003. In fact, the company has not suspended or ceased its activities, has not filed for bankruptcy, is not the subject of a legal liquidation, bankruptcy or arrangement procedure or a similar procedure set out by legislation or foreign regulations;

as of 31 December 2019, the members of the Board of Directors (including, where applicable, the companies present and their representatives) were:

as of 31 December 2020, the members of the Board of Directors were:

as of 31 December 2019, the members of the executive committee were:

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as of 31 December 2020, the members of the executive committee were:

no member of the Board of Directors or the executive committee has been the subject of a conviction in a final court judgement issued in the five years preceding the date herein for an offence affecting the probity of the company;

no member of the board of directors or of the executive committee has committed a serious misconduct in the exercise of their professional activity;

the company has met all its obligations concerning the payment of social-security contributions which are imposed by Belgian or foreign legislation;

the company has met all its obligations concerning the payment of direct and indirect taxes which are imposed by Belgian or foreign legislation;

no false statement has been made concerning the information required under the Decree of 12 April 2001 concerning the organisation of the regional electricity market and the Decree of 19 December 2002 concerning the organisation of the regional gas market or their implementing decrees.

Only to be completed by holders of a supply licence of electricity

The company :

☐ is its own BRP and itself balances its portfolio between injections and withdrawals ;

☐ uses the services of one or more third-party companies to balance its portfolio. This / these third party company (ies) are as follows

The company electricity to the residential sector and to be listed as such on the CWaPE website.

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Only to be completed by holders of a supply licence of gas

The company :

☐ is its own shipper and itself balances its portfolio between injections and withdrawals ;

☐ uses the services of one or more third-party companies to balance its portfolio. This / these third party company (ies) are as follows

The company gas to the residential sector and to be listed as such in the CWaPE website.

Only to be completed by holders of a supply licence limited to capped power of 10 MW (electricity)/a licence limited to a quantity of energy capped at 25 GWh (gas)

the company, which has a supply licence limited to power capped (of which the sum of the powers subscribed to it by its customers calculated on an annual basis is lower than) at 10 MW or a supply licence limited to a quantity of energy capped (of which the sum of the annual energy quantities supplied to its customers is less than) at 25 GWh/year, calculated on an annual basis, the 90 % threshold of this ceiling.

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Only to be completed by holders of a supply licence limited to specific customers

If this list has already been communicated to the CWaPE, please indicate the references of your letter:

Please indicate the full references of your letter

Otherwise, please complete the table below:

Customer name	Link with the company within the meaning of Article 11 of the Company Code.

List of appendices to be provided

Are you already the holder of an electricity or gas supply licence issued at federal level, in another region or in another member state within the European Economic Area?

☐ yes: please attach appendices 1, 2 and 3.

☐ no: please attach appendices 1, 2, 4 and 5.

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Appendix 1 :	copy(copies) of the amendments made to the company's articles of association since 31 December 2019 and/or decisions of the body which carried this out.

Appendix 2 :	company's business report and annual accounts for 2020 (if the latter are not available yet, please indicate the date when they will be).

Appendix 3 :	copy of the licence/authorisation to supply electricity and/or gas issued at federal level, in another region or in another member state within the European Economic Area (except if it has already been sent for a previous year, in which case please specify).

Appendix 4 :	criminal record extract (or equivalent document) dated within the last three months for:

Appendix 5 :	statement(s) concerning the absence of serious misconduct committed in the context of their professional activities from:

Drawn up at Click here to enter text

On Click here to enter a date

Your signature

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If the documents have already been sent to CWaPE by post, the reference number of the letter is sufficient.

Only criminal record extracts for new members (Board of Directors and executive committee) still active on this date are requested. If the new member is a company, please attach an extract of this company's criminal record and an extract for the person authorised to represent said company.

Statements are only required from new members (Board of Directors and executive committee). If these documents have already been sent to CWaPE by post, mention of the reference number and/or the letter date is sufficient.