Carlos Izquierdo Torres;mhto@statoil.com 2026-05-11T04:44:16+00:00 Writer LibreOffice 7.3 tetml={filename={D:\drim\repository\projects\drim_84_0\metadata\5\e\5eb281f12ed0515e7366197b6ee5aa63\5eb281f12ed0515e7366197b6ee5aa63.tet.xml} elements={annotations=false bookmarks=false destinations=false fields=false javascripts = false} } granularity=word contentanalysis={punctuationbreaks=false dehyphenate=false} layoutanalysis={tabledetect=0 layoutdetect=0} ANNEX 5 TO ITT INTEGRITY DUE DILIGENCE QUESTIONNAIRE Security Classification: Internal - Status: Draft Page PAGE 1 of NUMPAGES 1 granularity=word contentanalysis={punctuationbreaks=false dehyphenate=false} layoutanalysis={tabledetect=0 layoutdetect=0} INTEGRITY DUE DILIGENCE QUESTIONNAIRE greatly appreciates your cooperation in completing this form. According to Code of Conduct section 4.1, a business relationship with a potential counterparty can only be established or amended if the resulting relationship satisfies requirements for Integrity Due Diligence. Your provision to of complete and accurate information in response to the questions asked in this questionnaire is of critical importance because will be relying upon such information in deciding whether to do business with you or the firm that you represent, as the case may be, or in continuing an on-going business relationship with you or the firm that you represent. To the extent that this questionnaire asks you to provide personally identifiable information, -- shall take all reasonable steps to ensure that such information will be handled in full compliance with the applicable data protection/data privacy statutes and regulations. The term “Proposed Counterparty”, as it is used in this form refers to the party that might enter into a potential business relationship with --. It can be you or the firm that you represent, or both, as may be appropriate in the circumstances. 1. Name of person completing this form: Click here to enter text. 1.1. Address: Click here to enter text. 1.2. Telephone number: Click here to enter text. 1.3. Email address: Click here to enter text. 1.4. Name of Proposed Counterparty: Click here to enter text. 1.5. Former names: Click here to enter text. 1.6. Registered office address: Click here to enter text. 1.7. Head Office address: Click here to enter text. 1.8. Branch office: 1 Click here to enter text. 1.9. Name of Branch office: Click here to enter text. 1.10. Branch Office Address: Click here to enter text. 2. Proposed Counterparty information 1 A Branch Office is a second address for the same Proposed Counterparty with the same shareholders structure. Security Classification: Internal - Status: Draft Page PAGE 1 of NUMPAGES 1 granularity=word contentanalysis={punctuationbreaks=false dehyphenate=false} layoutanalysis={tabledetect=0 layoutdetect=0} 2.1. Type of organization a) Partnership Choose an item. b) Limited partnership Choose an item. c) Limited partnership with share capital Choose an item. d) Limited liability company Choose an item. e) Public limited liability company Choose an item. f) Other: Click here to enter text. 2.2. Country/City of incorporation/registration Click here to enter text. 2.3. Year and date established Click here to enter text. 2.4. Incorporation/registration number Click here to enter text. 2.5. Government Office where registered Click here to enter text. Please provide copies of the registration documents and English translations for all relevant registrations listed in this section 2.6. Number of employees Click here to enter text. 2.7. Country or countries in which the Proposed Counterparty does business Click here to enter text. 2.8. Website if available Click here to enter text. 3. Business Activities 3.1. Describe current business activities of the Proposed Counterparty Click here to enter text. 3.2. What is the Proposed Counterparty’s principal source of funds (e.g., trading revenues, state financing, etc.)? Please provide copies of any available documentation identifying the Proposed Counterparty’s principal source of funds (e.g., audited accounts, interim accounts, etc.). Click here to enter text. 3.3. If the Proposed Counterparty’s shares (stock) are traded on one or more stock exchanges, please identify which Click here to enter text. 3.4. Please provide the names of ALL direct and indirect owners of the Proposed Counterparty together with theirs ownership percentages. Only if the proposed Security Classification: Internal - Status: Draft Page PAGE 1 of NUMPAGES 1 granularity=word contentanalysis={punctuationbreaks=false dehyphenate=false} layoutanalysis={tabledetect=0 layoutdetect=0} counterparty is a publicly listed company, persons owning less than five (5%) percent of the Proposed Counterparty can be omitted unless they also are officers or directors of the Proposed Counterparty. If any of the owners is a company, please provide the names of the ultimate beneficial owner(s) and any intermediate entities or person owning an interest in that company. Please feel free to provide a chart to map the pertinent corporate structure. Please include supporting documentation of proof of shareholding. Full Name Ownership Percentage Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Additional information Click here to enter text. Click here to enter text. 3.5. Please list the names, nationalities and countries of residence of all officers and directors of the Proposed Counterparty. Full Name Nationality and Country of Residence Position(s) Officers/Directors Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Additional information Click here to enter text. Click here to enter text. Click here to enter text. 3.6. Please provide the name and position of the person(s) who will be principally responsible for the Proposed Counterparty’s relationship with --. Full Name Position Security Classification: Internal - Status: Draft Page PAGE 1 of NUMPAGES 1 granularity=word contentanalysis={punctuationbreaks=false dehyphenate=false} layoutanalysis={tabledetect=0 layoutdetect=0} Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Additional information Click here to enter text. Click here to enter text. 3.7. Please describe the services the Proposed Counterparty is expected to provide --. (Attach additional pages if necessary). Click here to enter text. 3.8. Please describe the experience that qualifies the Proposed Counterparty to provide to -- the services described in section 3.7. Click here to enter text. 3.9. Please indicate if the Proposed Counterparty has had previous business relationships with --. Click here to enter text. 3.10. Please describe the Proposed Counterparty’s relationship, if any, with Public Officials 2 or Politically Exposed Persons 3 Click here to enter text. 3.11. Does any Public Official(s) or Politically Exposed Persons have an ownership interest (direct, indirect, beneficial or otherwise), other financial interest or management role in the proposed counterparty? Choose an item. If “Yes” please identify each such Public Official(s) or Politically Exposed Persons, the nature of the relevant interest or management role and, if applicable, the ownership percentage or amount of the other financial interest. Full Name Interest/Management Role Ownership % or Amount Click here to enter text. Click here to enter text. Click here to enter text. 2 References to “Public Official” in this questionnaire include (i) elected or appointed officials, employees of national, regional or local government (such as inspectors, mayors, custom agents, and police officers), (ii) employees of government-owned or government-controlled entities or companies (such as state-owned oil companies, utilities, media organizations, health care institutions, sovereign wealth funds, and the like); (iii) employees of international public organizations (such as the United Nations, European Union, World Bank, and other international development agencies); (iv) political party officials or candidates for public office; (v) members of royal families; and (vi) any person “acting in an official capacity” on behalf of a government, government agency, government-owned enterprise, or public international organization. 3 “Politically Exposed Person” includes an individual who is or has, at any time in the preceding year, been entrusted with prominent public functions; or (ii) a close family member or close associate of such a person. The terms “close family member” and “close associate” are further defined below. Security Classification: Internal - Status: Draft Page PAGE 1 of NUMPAGES 1 granularity=word contentanalysis={punctuationbreaks=false dehyphenate=false} layoutanalysis={tabledetect=0 layoutdetect=0} Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Additional information Click here to enter text. Click here to enter text. Click here to enter text. 3.12. Do any of the following individuals hold a position with any government, government agency or department, international organization, enterprise owned in whole or in part by a government, public international organization or political party: a) Any owner, director or officer of the Proposed Counterparty Choose an item. b) A close family member 4 of an owner, director or officer of the Proposed Counterparty Choose an item. c) Any agent of or consultant to the Proposed Counterparty Choose an item. d) A close associate 5 of an owner, director or officer of the Proposed Counterparty Choose an item. If “Yes,” please identify all such individuals, their position and the corresponding governments, agencies or organizations. Full Name Position in or Relationship to the Proposed Counterparty Position in Government / Agency / Organization / Political Party Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. 4 For purposes of this questionnaire, the term “close family members” includes spouses, domestic/civil partners, children (either biological or adopted), grandchildren, parents, grandparents, or any other household member. 5 For these purposes, a “close associate” includes: (i) any person who is known to have joint beneficial ownership of a legal entity or legal arrangement, or any other close business relations, with a Public Official or Politically Exposed Person; and (ii) any person who has sole beneficial ownership of a legal entity or legal arrangement that is known to have been established for the benefit of a Public Official or Politically Exposed Person. Security Classification: Internal - Status: Draft Page PAGE 1 of NUMPAGES 1 granularity=word contentanalysis={punctuationbreaks=false dehyphenate=false} layoutanalysis={tabledetect=0 layoutdetect=0} Additional information Click here to enter text. Click here to enter text. Click here to enter text. 3.13. Have any of the individuals described in 3.12 previously held a position with any government, government agency or department, international organization, enterprise owned in whole or in part by a government, public international organization or political party? Choose an item. If “Yes,” please identify all such individuals, their position and the corresponding governments, agencies or departments, public international organizations, political party or other organization, and the dates of service. Full Name Position in or Relationship to the Proposed Counterparty Position in Government and Dates of Service Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Additional information Click here to enter text. Click here to enter text. Click here to enter text. NOTE: In answering sections 3.10, 3.11, 3.12 and 3.13 please include any affiliates (e.g., parent, subsidiary or sister companies) of the proposed counterparty and provide the requested information accordingly. 3.14. In providing the services needed by --, will the proposed counterparty rely upon consultants or others to interact with Public Official(s) or Politically Exposed Persons (e.g., obtaining permits or regulatory approvals or licenses, preparing reports for submission to Public Officials, government relations or lobbying, customs services, taxes)? Choose an item. If “Yes”, please answer the following questions: a) Please identify the consultants or others and provide a detailed explanation of the anticipated interaction with Public Officials or Politically Exposed Persons. (Attach additional pages if necessary.) Click here to enter text. Security Classification: Internal - Status: Draft Page PAGE 1 of NUMPAGES 1 granularity=word contentanalysis={punctuationbreaks=false dehyphenate=false} layoutanalysis={tabledetect=0 layoutdetect=0} b) How do you anticipate vetting the consultants and/or others from an anti-corruption perspective? Click here to enter text. c) How will the consultants and/or others identified above be compensated? (Attach additional pages if necessary.) Click here to enter text. d) Will any of the consultants and/or others identified above qualify as Public Officials or Politically Exposed Persons or close family members of a Public Official or Politically Exposed Persons ? Choose an item. If “Yes”, please describe in detail Click here to enter text. 3.15. Will or may any Public Official(s) or Politically Exposed Persons receive a pecuniary benefit if -- executes a contract with the Proposed Counterparty? Choose an item. If “Yes”, please identify the Public Official(s) or Politically Exposed Persons and describe the benefit that he or she will or may receive. Click here to enter text. 3.16. What assurances can you give -- that the proposed counterparty can be relied upon to comply with a contractual commitment not to bribe Public Officials or persons employed by another company in the private sector? Click here to enter text. 3.17. Is the proposed counterparty prepared to agree to a contractual commitment not to engage in bribery or any related form of corrupt behavior in providing services to --? Choose an item. If “No”, please explain Click here to enter text. 4. Proposed Counterparty standing and practices 4.1. Describe the policies and procedures that the Proposed Counterparty has adopted and implemented and the other actions that the Proposed Counterparty has taken to prevent bribery and other forms of corruption – in particular, the bribery of Public Officials and persons working for other companies in the private sector, and money laundering – and attach a copy of any such policies and procedures. Click here to enter text. 4.2. Has the Proposed Counterparty or any owners, directors, officers or employees of the proposed counterparty been a target of a criminal investigation or proceeding during the past five years involving allegations relating to the bribery of any Public Official or person working for other companies in the private sector, misleading record keeping or financial control deficiencies? Choose an item. Security Classification: Internal - Status: Draft Page PAGE 1 of NUMPAGES 1 granularity=word contentanalysis={punctuationbreaks=false dehyphenate=false} layoutanalysis={tabledetect=0 layoutdetect=0} If “Yes”, please describe the allegations that were made, how the allegations were resolved or, if not resolved, the current status of the investigation or proceedings. Click here to enter text. NOTE: Please include any affiliates (e.g., parent, subsidiary or sister companies) of the Proposed Counterparty. 4.3. Has the Proposed Counterparty or any owners, directors, officers or employees of the proposed counterparty ever been interviewed, deposed, or subpoenaed in connection with any litigation or investigation involving any procurement regulations? Choose an item. If “Yes”, please describe the allegations that were made, how the allegations were resolved or, if not resolved, the current status of the investigation or proceedings. Click here to enter text. 4.4. Has the Proposed Counterparty or any owners, directors, officers or employees of the Proposed Counterparty ever been interviewed, deposed, or subpoenaed in connection with any litigation or investigation involving any law governing donations, contributions, honoraria, or any other form of remuneration to any public official? Choose an item. If “Yes,” please describe the allegations that were made, how the allegations were resolved or, if not resolved, the current status of the investigation or proceedings. Click here to enter text. 4.5. Has the Proposed Counterparty or any owners, directors, officers or employees of the Proposed Counterparty been involved in any incident related to human rights and/ or labor rights controversy/legal charges? Choose an item. If “Yes,” please describe the allegations that were made, how the allegations were resolved or, if not resolved, the current status of the investigation or proceedings. Click here to enter text. 4.6. Has the Proposed Counterparty or any owners, directors, officers or employees of the Proposed Counterparty been involved in any incident related to environmental controversy/legal charges? Choose an item. If “Yes,” please describe the allegations that were made, how the allegations were resolved or, if not resolved, the current status of the investigation or proceedings. Click here to enter text. Security Classification: Internal - Status: Draft Page PAGE 1 of NUMPAGES 1 granularity=word contentanalysis={punctuationbreaks=false dehyphenate=false} layoutanalysis={tabledetect=0 layoutdetect=0} 4.7. Is the Proposed Counterparty or any owners, directors, officers or employees of the Proposed Counterparty or any party who controls the Proposed Counterparty currently on any sanction list? Choose an item. If “Yes”, please explain: Click here to enter text. 4.8. Has the Proposed Counterparty or any owner(s), director(s), officer(s) or employee(s) of the Proposed Counterparty or any party who controls the Proposed Counterparty been involved in any incident related to any allegations or charges of a breach of trade controls (being sanctions or export controls)? Choose an item. If “Yes,” please describe the allegations that were made, how the allegations were resolved or, if not resolved, the current status of the investigation or proceedings. Click here to enter text. 4.9. Does the Proposed Counterparty keep and maintain audited financial accounts? Choose an item. If “No”, please explain: Click here to enter text. 4.10. Please approximate the annual revenue and result of Proposed Counterparty for the past three (3) years. Click here to enter text. 4.11. Is the Proposed Counterparty prepared to agree to a contractual commitment permitting -- to audit the work the Proposed Counterparty does on behalf of --? Choose an item. If “No”, please explain: Click here to enter text. 4.12. Please provide the names of at least two commercial enterprises with which the Proposed Counterparty has worked as well as the name of a person at each such enterprise that is familiar with the work of the Proposed Counterparty. Enterprise 1 Enterprise 2 Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Security Classification: Internal - Status: Draft Page PAGE 1 of NUMPAGES 1 granularity=word contentanalysis={punctuationbreaks=false dehyphenate=false} layoutanalysis={tabledetect=0 layoutdetect=0} Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. 4.13. Please provide local banking reference for the Proposed Counterparty. a) Bank: Click here to enter text. b) Contact person: Click here to enter text. c) Position: Click here to enter text. d) Address: Click here to enter text. e) Telephone: Click here to enter text. f) Email: Click here to enter text. g) Please indicate any correspondent banks that may be involved in processing transactions/payments on your behalf: Click here to enter text. 4.14. Do you have any objection to -- or someone on behalf of -- contacting the commercial and banking references cited in 4.11 and 4.12. Choose an item. 4.15. Does the Proposed Counterparty have documented policies on compliance information: a) Ethical Code of Conduct ☐ NO ☐ YES b) Anti-Corruption ☐ NO ☐ YES c) Anti-Money Laundering ☐ NO ☐ YES d) Gifts and Hospitality ☐ NO ☐ YES e) Conflicts of Interest ☐ NO ☐ YES f) Integrity Due Diligence/background check on 3 rd parties ☐ NO ☐ YES g) Human Rights and Social Responsibility ☐ NO ☐ YES h) Labor standards 6 for direct employees and hired/contracted workers ☐ NO ☐ YES i) Environmental policy ☐ NO ☐ YES 6 Labor standards include ILO core principles (Freedom of Association and Collective Bargaining, Prohibition of Child Labor, Prohibition of Forced Labor and Freedom from Discrimination in Employment) and Terms of Employment (i.e. written employment contracts stating wages, working hours, social benefits etc. according to National laws). Security Classification: Internal - Status: Draft Page PAGE 1 of NUMPAGES 1 granularity=word contentanalysis={punctuationbreaks=false dehyphenate=false} layoutanalysis={tabledetect=0 layoutdetect=0} j) Sanctions and export controls policy ☐ NO ☐ YES If “Yes”, to any of the above please provide copies or links to the relevant policies. Please provide the name and contact details of a person that can further explain the content of these policies/processes. Click here to enter text. 4.16. Please indicate if the Proposed Counterparty or your Parent Company has been subject to any Integrity Due Diligence by the World Bank, International Finance Corporation, European Bank for Reconstruction Development or Trace International. Choose an item. If “Yes”, please provide a copy of or a link to the relevant evidences. Click here to enter text. 4.17. Is there any other information relevant to the proposed counterparty’s prospective relationship with --, which may affect --’s decision to do business with the proposed counterparty? If so, please give details. Click here to enter text. 5. Signature To be answered by the person who has completed this questionnaire: I believe the information provided in this questionnaire to be correct and complete. In the event that -- does business with the Proposed Counterparty, the Proposed Counterparty will inform -- of any material changes to the information supplied in this questionnaire. Signature:____________________________________ Date: Click here to enter text. Name: Click here to enter text. Position: Click here to enter text. Security Classification: Internal - Status: Draft Page PAGE 1 of NUMPAGES 1 0.00 0.00 0.00 1.00 0.07 0.26 0.12 0.29 0.49 1.00 0.00 0.00 0.58 0.21 0.20 0.00 0.69 0.31 0.50 0.50 0.50 0.75 0.00 0.00