Remittance Instruction

Service provider (agent): Masno UG (haftungsbeschränkt), Bieberer Straße 35A, 63065 Offenbach am Main, Germany — tied agent of Dalmar AS, Oslo (Reg. no. 998 081 432).

Please complete truthfully and in block letters. All fields marked * are mandatory.

1Sender (Ordering party)

Name of the organisation *

Legal form / register no. *

Registering court

Address (street, postcode, city, country) *

Tax number / charitable status

Authorised representative (name, role) *

Acting person / beneficial owner *

Phone / email *

2Order details

Order / reference no. *

Order date *

3Transfer details

Transfer amount (in figures) *

Currency *

Amount in words *

Source of funds *

Donations Association assets / own funds Public grant / funding Other:

Purpose of the transfer *

Humanitarian aid / emergency relief Project financing Support of beneficiaries / families Other purpose:

Detailed description of the purpose

4Beneficiary

Beneficiary name *

Address / city *

Destination country *

Relationship to the sender

Payout method / payout location

Account details / IBAN (if available)

5Declarations of the sender

By signing, the sender confirms:

The funds used are of legal origin and are freely available to the sender. Neither the sender, the acting person nor the beneficiary is subject to EU, UN or OFAC sanctions; there is no connection to sanctioned countries or persons. The transfer serves exclusively the purpose stated above. All information is correct and complete; any changes will be reported without delay. The sender agrees that Masno UG carries out the legally required identification and verification (KYC) under the German Anti-Money Laundering Act (GwG). The sender is aware that Masno UG acts as a tied agent of Dalmar AS.

6Place, date and signature of the sender

Place *

Date *

Signature *

Name in block letters / role *

Internal processing only — not to be completed by the sender

7Internal use — Masno UG

Received on / processed by

Identification/KYC performed (ID type, no.)

Sanctions/PEP screening performed on

DMTS reference / transaction no.

Approval (name, date)

Masno UG (haftungsbeschränkt) · Bieberer Straße 35A · 63065 Offenbach am Main · tied agent of Dalmar AS