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Page 4

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SECTION A
Tax Authority in/for


Tax identification number

CZ

    regular    X        corrected              additional


Causes of submitting an additional tax
return observed on                                                                                    Seal of Tax Authority




                                                                RETURN
                                                                for value added tax

                                 for a tax period of: month              1          quarter          XXX             year               2007


      1       Taxable person (Section 94)                   X                        2      Taxable person (Section 96)


              Non-taxable person (Section 29/5,6,
      3
              Section 108)




Corporate body:
Business firm:




Natural person:
Last name:                                                         First name:                                                 Title:




Seat of business of corporate body or permanent residence of natural person:
a) municipality                                                    b) postcode                  c) telephone no.

0
d) street and number (or municipality section and number)                                       e) fax no.

                                                                                                0
f) region                                                                                       g) country

                                                                                                Czech Republic


Other information:
Key economic activities:




                           Formulář zpracovala ASPEKT HM, daňová, účetní a auditorská kancelář, Bělohorská 39, Praha 6-Břevnov, www.aspekthm.cz
25 5401 Mfin 5401 vzor č.13
                                                                          1
SECTION B - Value added tax
      I. Cross out (X) if no tax chargeable
      II. Tax chargeable for                                                                        Taxable amount       Tax on output
line 1. taxable transactions with a local place of supply
210 standard tax rate                                                                                                0                     0
215 reduced tax rate                                                                                                 0                     0
      2. goods acquired from a Member State (Sections 16 and 17(6)(e), except for Section 19)

220 standard tax rate                                                                                                0                     0
225 reduced tax rate                                                                                                 0                     0
      3. services supplied by a taxable person from a Member State (Sections 15 and 13(8))

230 standard tax rate                                                                                                0                     0
235 reduced tax rate                                                                                                 0                     0
      4. goods dispatched from a Member State with a local place of supply (Section 18)

240 standard tax rate                                                                                                0                     0
245 reduced tax rate                                                                                                 0                     0
      5. acquisition of new transport vehicles
250 from persons taxable in a Member State (Section 19(3))                                                           0                     0
255 from persons non-taxable in a Member State (Section 19(4))                                                       0                     0
      6. important of goods (Section 20)
260 standard tax rate                                                                                                0                     0
265 reduced tax rate                                                                                                 0                     0
      7. services supplied by a taxable non-resident (Sections 15 and 13(8))
270 standard tax rate                                                                                                0                     0
275 reduced tax rate                                                                                                 0                     0
                                                                                                    Tax on input (full     Tax on input
      III. Right to deduction for transactions of                              Taxable amount
                                                                                                         claim)          (reduced claim)
      1. incoming taxable transaction with a local place of supply
310 standard tax rate                                                                           0                    0                     0
315 reduced tax rate                                                                            0                    0                     0
      2. goods acquired from a Member State (Sections 16 and 17(6)(e),
      except for Section 19)

320 standard tax rate                                                                           0                    0                     0
325 reduced tax rate                                                                            0                    0                     0
      3. services supplied by a taxable person from a Member State
      (Sections 15 and 13(8))

330 standard tax rate                                                                           0                    0                     0
335 reduced tax rate                                                                            0                    0                     0
      4. importation of goods (Section 20)
340 standard tax rate                                                                           0                    0                     0
345 reduced tax rate                                                                            0                    0                     0
      5. services supplied by a taxable non-resident (Sections 15 and
      13(8))

350 standard tax rate                                                                           0                    0                     0
355 reduced tax rate                                                                            0                    0                     0
      6. acquisition of new transport vehicles
360 from persons taxable in a Member State (Section 19(3))                                      0                    0                     0
365 from persons non-taxable in a Member State (Section 19(4))                                  0                    0                     0
370 7. change of regime                                                                                              0                     0
      total sum of reduced claim to right to deduction (lines
380
      310+315+320+325+330+335+340+345+350+355+360+365+370)
                                                                                                                                           0
      total sum of full claim to right to deduction (lines
390
      310+315+320+325+330+335+340+345+350+355+360+365+370)                                                           0
2
     IV. Transactions exempted from tax with a right to deduction                                                                Transaction amount
410 supply of goods to a Member State (Section 64, except fro Section 64(2) and Section 17(2))                                                        0

420 supply of new transport vehicles to a Member State (Section 64(2)) to a person taxable in a Member State                                          0

425 supply of new transport means to a Member State (Section 64(2)) to a person non-taxable in a Member State                                         0

430 exportation of goods (Section 66)                                                                                                                 0
440 other transactions exempted from trax with a right to deduction                                                                                   0
     V. Total transactions                                                                                                       Transaction amount
510 Total transactions with a right to deduction (Section 72(2)(a) through (d))                                                                       0
520 Transactions not included in coefficient calculation (Section 76(3)) out of transactions in line 510                                              0
530 Total transactions exempted from tax without a right to deduction (Section 51)                                                                    0
540 Transactions not included in coefficient calculation (Section 76(3) out of transaction in line 530                                                0
     Reduction, settlement, adjustment and compensation of tax deduction                                    Coefficient        Change in tax deduction
550 Calculated proportion of tax deduction (Section 76)                                                               0.00                            0
560 Settlement of tax deduction (Section 76(7-10))                                                                    0.00                            0
570 Adjustment of tax deduction (Section 78)                                                                                                          0
580 Compensation of tax deduction (Section 79)                                                                                                        0
     VI. Tax refund (Section 84)                                                                                                   Tax on output
600 Tax refund                                                                                                                                        0
     VII. Chargeable tax                                                                                   Tax deduction           Tax on output
710 Settlement of tax on output (Section 91)                                                                                                          0
    Tax on output (lines 210+215+220+225+230+235+240+245+250+255 +260+265+270+275-
730
    600+710)
                                                                                                                                                      0

750 Tax deduction (lines 390+550+560+570+580 )                                                                             0
753 Chargeable tax (lines 730-750 )                                                                                                                   0
754 Deduction excess (lines 750-730 )                                                                                      0
780 Change in chargeable tax upon submission of additional return (lines 730-750 )                                                                    0
     VII. Additional information
     1. Total sum of simplified procedure for supply of goods within the European
     Economic Community in a three-party transaction (Section 17)

810 Acquisition of goods through an AGENT                                                                                                             0
815 Supply of goods through an AGENT                                                                                                                  0
All figures should be given in whole Czech Crowns.




                                                                            3
SECTION C
               HEREBY, I REPRESENT THAT ALL THE INFORMATION GIVEN HEREIN ARE TRUE AND COMPLETE.


Person authorized to act on behalf of taxable person
Last name                                                                              First name
0                                                                                      0
for a corporate body: relation to the corporate body




         10/1/2011                     Seal
             Date                                                                            Signature


Issued by                      0                                                                         Tel.:   0

The Tax Authority assessed the reported tax/made an additional assessment under Section 46 of ČNR Act no. 337/1997 Coll. on adminis-
tration of taxes and fees, as amended on:                                                      As of




                                                                                           Signature of authorized representative of Tax Authority




                                                                       4
       Taxable                                                       Right = 1
Line   amount        VAT         Rate        Correct VAT Difference Wrong = 0
210              0         0            19             0           0    1
215              0         0             5             0           0    1
220              0         0            19             0           0    1
225              0         0             5             0           0    1
230              0         0            19             0           0    1
235              0         0             5             0           0    1
240              0         0            19             0           0    1
245              0         0             5             0           0    1
250              0         0            19             0           0    1
255              0         0             5             0           0    1
260              0         0            19             0           0    1
265              0         0             5             0           0    1
270              0         0            19             0           0    1
275              0         0             5             0           0    1
310              0         0            19             0           0    1
315              0         0             5             0           0    1
320              0         0            19             0           0    1
325              0         0             5             0           0    1
330              0         0            19             0           0    1
335              0         0             5             0           0    1
340              0         0            19             0           0    1
345              0         0             5             0           0    1
350              0         0            19             0           0    1
355              0         0             5             0           0    1
360              0         0            19             0           0    1
365              0         0             5             0           0    1



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