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"AGREED"*

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Minsk City Executive Committee

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(signature and decryption of the signature)

«___» _____________ 20____

LIST OF GOODS (WORKS, SERVICES), PROPERTY RIGHTS PURCHASED (IMPORTED TO THE TERRITORY OF THE REPUBLIC OF BELARUS) AND USED FOR DESIGNING, CONSTRUCTION (RECONSTRUCTION), EQUIPMENT OF FACILITIES PROVIDED FOR IN THE INVESTMENT PROJECT WHICH IS IMPLEMENTED IN ACCORDANCE WITH THE INVESTMENT CONTRACT WITH THE REPUBLIC OF BELARUS.

  1. Investor: ___________________________________ (full name and ANP (for legal entities) or surname, first name, patronymic and ANP (for individual entrepreneurs)
  2. Investment contract between ____________________ (name of investor) and the Republic of Belarus dated __________ (No. and date of conclusion of the contract) on the implementation of the investment project for ___________________ (name of the investment project) registered in the State Register of Investment Contracts with the Republic of Belarus ________________ (No. and date of registration).
  3. Name of the facility: __________________________ (in accordance with the investment contract).
  4. The period for which VAT is charged: __________________________.
  5. List of goods (works, services), property rights:
Description of goods 
(works,, services)
Quantity of goods Cost of goods (works, services) property rights , Amount of VAT paid for goods (works, services), property rights   Requisites of documents **, confirming the use of goods 
(works, services), property rights
Requisites of documents **, confirming payment for goods
(works, services), property rights
Requisites of documents ** (customs declarations), confirming the purchase (import to the territory of the Republic of Belarus) of goods (works, services), property rights
               
  TOTAL:            

Director
Chief Accountant

*The "AGREED" stamp is attached to each page of the list
** indicate the name of the document, the date of its drawing up and the number (if any)