Outbound Investment Notification Form

U.S. DEPARTMENT OF THE TREASURY

Submission Form for Notifications Under 31 C.F.R. Part 850

IMPORTANT: All fields on this form are required unless otherwise explicitly noted.

1. The contact information of a representative of the U.S. person filing the notification to communicate with about the notification including name, title, email address, mailing address, phone number, and employer:

Name:

Title:

Email address:

Mailing address:

Phone number

Employer:

2. A description of the U.S. person, including name, and as applicable, principal place of business and place of incorporation or legal organization, company address, website, and, if the U.S. person is an entity, such U.S. person’s ultimate owner;

Name:

Principal place of business:

Place of incorporation or legal organization:

Company address:

Website:

U.S. person’s ultimate owner (if U.S. person is an entity):

3. A post-transaction organizational chart of the U.S. person that includes its relationship with any controlled foreign entity or entities of the U.S. person and that identifies the covered foreign person or persons involved in the transaction;

4. A brief description of the commercial rationale for the transaction:

5. A brief description of why the U.S. person has determined the transaction is a covered transaction that includes a discussion of the nature of the transaction, its structure, reference to the paragraph of § 850.210(a) that best describes the transaction type, and whether the notification is being submitted pursuant to § 850.401, § 850.402, or § 850.403.

6. The status of the transaction, including the actual or expected completion date of the transaction:

7. The total transaction value in U.S. dollars or U.S. dollar equivalent and an explanation of how the transaction value was determined and a description of the consideration for the transaction (including cash, securities, other assets, and debt forgiveness);

8. The aggregate equity interest, voting interest, board seats (or equivalent holdings) of the U.S. person and its affiliates in the covered foreign person (or in the joint venture, as applicable) following the completion date of the transaction, including a description of any agreements or commitments for future investment or options to make investments in the covered foreign person (or joint venture);

9. Information about the covered foreign person, including its name, and as applicable, principal place of business and place of incorporation or legal organization, company address, website, and if the covered foreign person is an entity, such covered foreign person’s ultimate owner, and the full legal names and titles of each officer, director, and other member of management of the covered foreign person, and a post-transaction organizational chart of the covered foreign person;

Name:

Principal place of business:

Place of incorporation or legal organization:

Company address:

Website:

Covered foreign person’s ultimate owner (if person is an entity):

Full legal names and titles of each officer, director, and other member of management:

Post-transaction organization chart of the covered foreign person:

10. Identification and description of each of the covered activity or activities undertaken by the covered foreign person that makes the transaction a covered transaction, as well as a brief description of the known end use(s) and end user(s) of the covered foreign person’s technology, products, or services;

11. A statement describing the attributes that cause the entity to be a covered foreign person, and any other relevant information regarding the covered foreign person and covered activity or activities;

12. If a transaction involves a covered activity identified in § 850.217(a), (b), or (c), identification of the technology node(s) at which any applicable product is produced; and;

13. If the notification is required under § 850.403:

(i) Identification of the fact or circumstance of which the U.S. person

acquired knowledge post-transaction;

(ii) The date upon which the U.S. person acquired such knowledge;

(iii) A statement explaining why the U.S. person did not possess or

obtain such knowledge at the time of the transaction; and

(iv) A description of any pre-transaction diligence undertaken by the U.S. person, including, as applicable, any steps as described in § 850.104(c).

14. Attach here a certification from the U.S. person submitting the notification that the information contained in the form is consistent with 31 C.F.R. 850.405.