Value added tax return considered as annual return Closing down of business in 2014

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1 For official use only Date of entry Accounted for Central Tax Office P.O. Box 1004 L Luxembourg Tel.: (+352) IBAN LU BIC Code: CCPLLULL Value added tax return considered as annual return Closing down of business in 2014 A (Law of as subsequently modified) Statutory deadline for filing the return and payment of tax: on page 4 (Name and first name, or corporate name) (Street and house number) (Country code, post code and city) I. ASSESSMENT OF TAXABLE TURNOVER A. Overall turnover 1. VAT accounting scheme: on sales 204 on payments received 205 (tick as appropriate) 2. Total Sales / Receipts (taxed, exempt and out of national scope transactions, according to business branch) Amounts VAT excluded (1) (a) Supply of inhouse manufactured goods 001 (b) Supply of goods not manufactured inhouse (c) Net profit margin (special arrangement: Art. 56ter) (2) Supply of services (3) Disposal of tangible and intangible capital assets when those transactions are ancillary transactions (4) (1) Application of goods for private use or for that of the staff (Art. 13(a)) (2) Application for the purpose of business of goods produced in the course of the business (Art. 13(b)) (3) Use of goods considered business assets for purposes other than those of the business (Art. 16(a)) (4) Supply of services carried out free of charge for purposes other than those of the business (Art. 16(b)) Total turnover 012 B. Exemptions and deductible amounts 5. (a) Intra-Community supply of goods to persons identified for VAT purposes in another Member State (MS) (Art. 43(1)(d), (e) and (f)) *) 013 (b) Intra-Community supply of new means of transport to persons not identified for VAT purposes who are established or reside in an other MS (Art. 43(1)(e)) Exports (Art. 43(1)(a) et (b)) Other exemptions (Art. 43 and 56sexies) Other exemptions (Art. 44 and 56quater) Manufactured tobacco Transactions carried out (for which the place of supply is) abroad: (a) Supply, subsequent to intra-community acquisitions of goods, in the context of triangular transactions, when the customer identified for VAT purposes in the MS of destination of the goods is liable for payment of VAT in that MS *) (b) Supply of goods (other than new means of transport and products subject to exise duty), dispatched or transported by or on behalf of the supplier, carried out to customers not identified for VAT purposes and established or residing in the MS where the dispatch or transport ends, when these supplies are taxable in that MS (distance selling) (c) Supply of services, other than exempted from VAT in the customer's MS, to customers identified for VAT purposes in another MS, for which the customer is liable for VAT *) (d) Supply of services to customers identified for VAT purposes in another MS, exempt in the customer's MS (e) Other supplies carried out (for which the place of supply is) abroad Inland transactions for which the customer is liable for the payment of VAT: Total to deduct (under point C) 021 C. Taxable turnover (net of VAT) : point 4 (total turnover) minus point 12 ( ) 022

2 - 2 - II. ASSESSMENT OF VAT DUE (output tax) Taxable amount (net of VAT) Tax 13. Breakdown of taxable turnover: rate of Intra-Community acquisitions of goods: rate of Total point 13: Intra-Community acquisition of goods (Art. 18(1)) - Application, for the purposes of business, of goods transferred from another MS (Art. 18bis) - Supply of goods, made within the territory in the context of triangular transactions and for which the declaring person is liable for payment of VAT exempt Importation of goods rate of Total point 14: (1) for business purposes exempt (2) for non-business purposes exempt Total point 15, (1) + (2): Supply of services for which the customer is liable for the payment of VAT (1) provided to the declaring person by suppliers established or residing in another MS of the Community rate of Subtotal taxable amount point 16(1): 436 exempt (2) provided to the declaring person by suppliers not established or residing within the Community exempt Total point 16, (1) + (2): (3) provided to the declaring person by suppliers established within the territory

3 Supply of goods for which the purchaser is liable for the payment of VAT rate of Total taxable amount points (= ) : Special arrangements for tax suspension: adjustment (Art. 56sexies, (5) and (8)) Total tax due (= ) (to be carried forward to point 31) 076 III. ASSESSMENT OF DEDUCTIBLE TAX (input tax) (a) Stock entries (b) Capital expenditures (c) Operational expenditures 20. VAT invoiced by other taxable persons for goods or services supplied VAT due in respect of intra-community acquisitions of goods other than manufactured tobacco VAT due or paid in respect of importations of goods other than manufactured tobacco and goods for non-business purposes VAT due under the reverse charge (cf. points 16 and 17) Total (c) 088 Total (b) Total (a) Tax due in respect of the application of goods for business purposes as referred to in Art. 13(b) (cf. point 3.2) Tax paid as joint and several guarantee in accordance with the conditions laid down in Art Adjusted tax - special arrangements for tax suspension (Art. 56sexies(9), subpar. 2) (1) Non recoverable input tax relating to supplies exempt pursuant to Art. 44 and 56quater (2) Non recoverable proportion of input tax determined in accordance with Art (3) Non recoverable input tax in accordance with Art. 56ter(4) (when applying the margin scheme) Adjustment of deductions (a decrease of the recoverable input tax has to identified by a minus sign) 28. (1) in accordance with provisions of Art (2) in accordance with provisions of the grand-ducal Regulation of 7 March option to tax land Other: Total input tax deductible (to be carried forward to point 32) 102 IV. VAT to be paid or to be reclaimed 31. Total tax due (brought forward from point 19) Total tax deductible (brought forward from point 30) Exceeding amount: (a possible input tax surplus has to be identified by a minus sign) 105 A surplus of input tax shall be refunded by a transfer to the bank account the declaring person has indicated to the Administration.

4 - 4 - V. Additional information 34. Accounting period 233 / 234 / / 236 / 2014 Day Month Day Month 35. Phone number for contacting the declaring person: Number of persons employed (average for the year): - with salary or wage with no salary (family members) 109 = Taxable persons established in Luxemburg: place of storage of books, records and documents the keeping, drafting and issuing of which are required by the VAT law of 12 February 1979 and its implementing provisions, when this place of storage is outside of the territory of Luxemburg Acquisitions, in the context of triangular transactions, made for a subsequent supply to a customer identified for VAT purposes in the MS of destination of the goods, and for which that customer has been designated as liable for the payment of VAT (Art. 18ter(2), subpar. 2) 152 Ad *) page 1: Amounts entered into lines 013, 018 or 423 match the sums of the corresponding sections of the recapitulative statements submitted for the The undersigned hereby certifies/certify that the information given in this return is true and complete., Date Signature(s) Statutory deadline for submission of this return and payment of tax: within 2 months following closing down of business in Submission of the return and payment of the tax have to be made to: Recette Centrale de l'enregistrement Account: P.O. Box 1004 IBAN LU L Luxembourg BIC Code: CCPLLULL Profit and loss statement has to be attached when keeping adequate and orderly accounting records. The annexed forms are to be filled in accurately and filed jointly with the return.

5 - 5 - Registation nr. Appendix to the 2014 VAT return (A) Operational expenditures 1. Gross salaries 2) TOTAL if applicable VAT included BUSINESS PORTION VAT excluded of VAT invoiced 1) For official use only of which productive salaries Gross wages 2) Occasional salaries Compulsory social security contributions (employer's share) Accident insurance ) 6. Commissions Staff travel and representation expenses ) 9. Accounting and bookkeeping fees (Indicate name and address of accountant on page 8 point (E) Employer's travel and representation expenses Electricity Gas Water Heating Telecommunications Renting/leasing of 4) a) immovable property with application of VAT (Indicate name and address of lessor on page 8 point (E) b) immovable property with no application of VAT c) permanently installed equipment and machinery Fire insurance Property tax Business tax Licensing (cabaretage) tax and other taxes Interest paid for long-term debts Interest paid for short-term debts Other financial costs Stock and business equipment insurance Public and professional third party liability insurance Office expenses Cleaning and maintenance of business premises Fees and subscriptions paid to professional associations and learned societies Papers and periodicals for business purposes to be carried forward

6 Expenses for work carried out by third parties brought forward: a) expenses for work carried out by sub-contractors b) expenses for other work carried out by third parties Shipping and transport expenses Work clothes Advertising and publicity Packaging Repair and maintenance of equipment and machinery Other repairs New acquisitions (tools and equipment) if their cost can be fully allocated to the year of acquisition or creation pursuant to Article 34 of Income Tax Law Total 'Appendix to Operational expenditures' (brought forward from page 9) 5) Car expenses Total Operational Expenditures (B) Assessment of the taxable amount 6) for non-business use of assets allocated to business Art. 16(a) I. Motor vehicles Book (net asset) value Acquisitions in Sales in Depreciation for to be carried forward to point 5 below 7) Book (net asset) value at the time 367 of business closure TOTAL expenses VAT excluded VAT 1. Fuel (petrol, diesel) and lubricants LPG Repairs and servicing Tyres, etc Leasing / renting Depreciation 7) Total: 382 Total kilometres travelled in 2014: 383 km Non-business portion: 384 km = = 386 II. Other assets: III. Total to be carried forward to point 3(3) of the annual return = 389 Comments: 1) Exclusively VAT actually invoiced; please do not show VAT due in respect of intra-community acquisitions of goods and importation of goods or VAT due under the reverse charge. 2) Not including payments on behalf of third parties (e.g. sickness benefits advanced on behalf of the national healthcare system - Caisse Nationale de Santé - and which will be reimbursed by the latter). 3) Including all special taxes (e.g. solidarity tax) charged on salaries and wages. 4) Deduction of VAT in respect of operating costs can be refused if the supplier's name is not or cannot be indicated. 5) A detailed list of expenses not listed under point (A) of the appendix to the annual return can be joined as 'Appendix to Operational expenditures'; total sums of such an 'Appendix' are to be carried forward to line 43 of point (A). 6) The taxable amount shall be the full cost of providing the services. 7) Only if the person declaring was or is able to reclaim VAT paid or declared in respect of the car's purchase.

7 - 7 - (C) Entry of stock for business purposes (all amounts VAT excluded) not falling within the scope of Art. 56ter 1) 1. Purchases of goods (within the territory of Luxembourg or abroad and subsequently brought to Luxembourg) which give rise to a chargeable event for the supplier or for the taxable person acquiring the goods (a) Purchases within the country 2) (b) Intra-Community acquisitions (c) Imports 3) 1.1. at the rate of ) 4) exempt Subtotal: ) Manufactured tobacco ) + Total (c) 147 Total (b) Total (a) Purchases of goods (within the territory of Luxembourg or abroad and subsequently brought to Luxembourg) which don't give rise to a chargeable event neither for the supplier nor for the taxable person acquiring the goods Purchases of goods abroad which are not brought to Luxembourg Total entry of stock 154 of which goods for resale 155 1) Does not pertain to goods categorised as capital or operational expenditures. 2) Including electricity, gas, heat and cooling energy supplied by a taxable person not established in Luxembourg, when the person declaring is liable for the payment of VAT under the reverse charge mechanism. 3) Including taxes, duties, levies and other charges, excluding VAT itself, as well as incidental expenses, such as commission, packing, transport and insurance costs, incurred up to the first place of destination within the country. The taxable amount shall also include any of the afore-mentioned incidental expenses resulting from transport to another place of destination within the Community, if that other place is known when the chargeable event occurs (Art. 34). 4) Agricultural products purchased from a taxable person applying the flat-rate scheme for farmers. 5) Price stated on the tax label less VAT included.

8 - 8 - (D) Stock / Miscellaneous (amounts VAT excluded) rate (1) Stock not falling within the scope of Art. 56ter and manufactured tobacco referred to in (D)(2) excluded Date of business closure / exempt Subtotal: (1) of which - stock for resale: goods produced inhouse: (2) Manufactured tobacco in stock (2) (3) Total (1) + (2) (4) Work in progress (VAT excluded) (5) Receivables from clients (VAT excluded) (6) Payments made on account by clients (VAT excluded) E) Names and addresses to be specified - points 9 and 18(a) of (A) (A)(9) Accountant: Name 397 Address (A)(18)(a) Lessor: Name 400 Address F) Annual accounts: submitted to the Trade and Companies Register (RCSL): Yes 998 No 999 (tick as appropriate)

9 (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23) (24) (25) (26) (27) (28) (29) (30) (31) (32) (33) (34) (35) (36) (37) (38) (39) (40) (41) (42) (43) (44) (45) (46) (47) (48) (49) (50) Appendix to Operational expenditures Detail of expenses referred to in (A)(43) of the appendix to the annual return 411 VAT excluded 412 Business portion of VAT invoiced 1) 413 For official use only Total to be carried forward to (A)(43) of the appendix to the annual return

10 Appendix to the 2014 VAT return Date of entry For official use only Accounted for Sequential nr. 501 Date of acquisition Acquisitions of depreciable/amortisable capital expenditures Acquisitions which cost cannot be fully allocated to the year of acquisition or creation pursuant to Article 34 of Income Tax Law Description Acquisition cost (when VAT included) VAT Acquisition cost (VAT excluded) Subsidies received 1) Value to be depreciated/amortised 1) Column 6 minus column 7: to be carried forward to columns 4 and 7 of the depreciation table TOTAL:

11 Sequential nr. 501 Acquisitions of depreciable/amortisable capital expenditures Date of acquisition Description Acquisition cost (when VAT included) VAT Acquisition cost (VAT excluded) Subsidies received 1) Value to be depreciated/amortised

12 2014 Depreciation/amortisation Table Sequential nr. 617 Date of acquisition Designation Value to be depreciated or amortised Deprec. or amort. Book (net asset) value at the beginning of ) Acquisitions during 2) Sales during Depreciation or amortisation cost Book (net asset) value at the end of 1) For details, see table of acquisitions 2) VAT excluded Non-business portion : 615 Business portion: 616

13 Depreciation/amortisation Table 617 Sequential nr. Date of acquisition Designation Value to be depreciated or amortised Deprec. or amort. Book (net asset) value at the beginning of ) Acquisitions during 2) Sales during Depreciation or amortisation cost Book (net asset) value at the end of

VALUE ADDED TAX (Law of as subsequently modified)

VALUE ADDED TAX (Law of as subsequently modified) Page 1/13 Recette Centrale B.P. 1004 L-1010 Luxembourg Tél. (1) : (+352) 247-80800 IBAN : LU31 1111 0114 1970 0000 Code BIC : CCPLLULL URL (1) : http://www.aed.public.lu Statutory deadline : Tax office