BEE SWORN AFFIDAVIT - BusinessNeeds Online

1 SWORN AFFIDAVIT B-BBEE EXEMPTED micro ENTERPRISE I, the undersigned, Full Name & Surname: Identity Number: Hereby declare under oath as follows: 1. The contents of this statement are to the best of my knowledge a true reflection of the facts. 2. I am a Member / Director / Owner of the following Enterprise and am duly authorised to act on its behalf: Enterprise Name: Registration Number: Enterprise Address: VAT Number (only if registered for VAT): 3. I hereby declare under oath that: The Enterprise is _____% black owned (shareholding) and these shareholders are all South African citizens. The Enterprise is _____% black woman owned (shareholding) and these shareholders are all South African citizens. The Black Shareholders (if applicable) are either African, Coloured, Indian or Chinese South African Citizens, and they were born in South Africa OR one of their Parents was a SA citizen when they were born OR they obtained their Citizenship before 27 April 1994.

2 I also confirm that their Ownership is fully realised and they share in all profits declared and have full voting rights as per their Ownership percentage in the above Entity. Based on the management accounts and other information available for the last financial year, the income / sales / turnover did not exceed R10 000 000 (ten million Rands) Please confirm on the table below the B-BBEE level contributor, by ticking the applicable box (tick only one of the 3 boxes below). 100% black owned Level One (135% B-BBEE procurement recognition) More than 51% black owned but less than 100% black owned Level Two (125% B-BBEE procurement recognition) Less than 51% black owned or white owned Level Four (100% B-BBEE procurement recognition) 4. The Entity is an empowering supplier in terms of the DTI Codes of Good Practice. 5. The Entity does not have a stake / relationship in / with any related businesses / parties to intentionally spread revenue / income over multiple business for the sake of qualifying this business for EME status.

3 In the case the Entity does have a stake / relationship in / with any related business / party, the joint revenue of all these related businesses is less than R10 million. 6. I know and understand the contents of this AFFIDAVIT and I have no objection to take the prescribed oath and consider the oath binding on my conscience and on the Owners of the Enterprise which I represent in this matter. I know that any misrepresentation constitutes a criminal offence. Initiatives that split, separate or divide Enterprises as a mean of ensuring eligibility as an Exempted micro -Enterprise or a Start-Up Enterprise are a circumvention of the law and may lead to the disqualification of the entire scorecard of those Enterprises concerned. I agree that anyone implicated in the misrepresentation of any information for my Enterprise s B-BBEE status, risks criminal prosecution and up to 10 years imprisonment.

4 7. The SWORN AFFIDAVIT will be valid for a period of 12 months from the date signed and stamped by the Commissioner of Oaths. Date: Deponent Signature: Commissioner of Oaths Signature and Stamp