EIB 10-01B Oil and Gas Company Questionnaire

Export-Import Bank

of the United States

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EIB10-01B

OMB 3048-xxxx

Expires:

Questionnaire Regarding Activities related to the Islamic Republic of Iran

The Export-Import Bank of the United States (“Ex-Im Bank”) is prohibited from supporting transactions involving parties that conduct certain business related to the Iranian energy sector. To facilitate compliance, Ex-Im Bank requires your company to complete and return this Questionnaire to Ex-Im Bank within ten days. In addition, Ex-Im Bank reserves the right to ask further questions as necessary.

Part A: General Information

1. Company Information:

Company Name: ____________________

Address: ____________________

____________________

____________________

Contact:

Name and Title: ____________________

Telephone: ____________________

Email: ____________________

Part B: Description of Business Dealings with Iran

1. Does the company (or any other companies controlled¹ by the company) provide Iran or any Iranian entity with refined petroleum resources, or is the company currently negotiating to do so? If yes, please provide a detailed explanation, including but not limited to the amounts of petroleum, monetary value, timeframes, parties and counterparties, and other details of the transactions or proposed transactions.

2. Does the company (or any other companies controlled by the company) contribute in any way to Iran’s capability to import refined petroleum resources, or is the company currently negotiating to do so? If yes, please provide a detailed explanation, including but not limited to themonetary value, timeframes, parties and counterparties, and other details of the transactions or proposed transactions.

3. Does the company (or any other companies controlled by the company) have any role in allowing Iran to maintain or expand its domestic production of refined petroleum resources, including any assistance in refinery construction, modernization or repair, or is the company currently negotiating to have such a role? If yes, please provide a detailed explanation, including but not limited to the monetary value, timeframes, parties and counterparties, and other details of the transactions or proposed transactions.

Part C: Certification

Certification. The submitter of this questionnaire (“Submitter”) certifies that the facts stated and the representations made above and in any attachments to this Questionnaire are true, to the best of the Submitter’s knowledge and belief after due diligence, and that the Submitter has not misrepresented or omitted any material facts. The Submitter further understands that this is an official submission to the United States Government and this Certification is subject to the penalties for fraud against the U.S. Government (18 U.S.C. § 1001, et. seq.). The Submitter further certifies that it will provide additional information with respect to any of the matters covered in this Questionnaire upon Ex-Im Bank’s request. The authorized officer or employee signing below is fully authorized to certify the answers in this Questionnaire on behalf of the Submitter.

Company Name: ___________________________

By: ___________________________

(Authorized Officer or Employee)

Name:

Title:

Date: ___________________________

Public Burden Statement - Reporting for this collection of information is estimated to average xx hours per response, including reviewing instructions, searching data sources, gathering information, and completing and reviewing the application. Send comments regarding the burden estimate, including suggestions for reducing it, to Office of Management and Budget, Paperwork Reduction Project OMB# 3048-XXXX, Washington, D.C. 20503.

1 For purposes of this questionnaire, “control” means either (a) holding a 50 percent or more of the voting securities of an issuer, or (b) having the contractual power presently to designate a majority of the directors of a corporation (or, in the case of an unincorporated entity, a majority of the individuals who exercise similar functions).

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