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Tax Incentives Application - Puerto Rico Department Of Economic Development And Commerce Page 6

SWORN STATEMENT

I, ___________________________, of legal age, _______________________, and resident of

_________________________ under the most solemn and binding oath, under penalty of

perjury, hereby declare that:

1. such are my personal circumstances;

2. my official title is _________________________________________ ;

3. I have been authorized by the Applicant to complete this Application;

4. I have read the foregoing Application and attachments and that the statements contained

herein are true to the best of my personal knowledge and belief.

Signature

Date

AFFIDAVIT NUMBER: ________________________

Sworn and subscribed before me by ______________________________________________, of

the personal circumstances stated above to me personally known.

On the ___ day of _____________ of _____.

Notary Public

Notes:

a. The Application must be sworn by an Officer of the Applicant, authorized by Corporate

Resolution.

b. If this document is notarized outside of Puerto Rico, include evidence regarding the authority

of the notary to administer oaths (e.g., county clerk’s certificate or similar document).

Tax Incentives Application - Puerto Rico Department Of Economic Development And Commerce Page 6