Name of Taxpayer: ×××××× 

Sex: ××××

Age: ××

Citizenship: China

Passport No.:

ID Card No.:××××××××××××××

Address in China

#××-××-××-×× Fengyuan Apartment

Dalian City, Liaoning Province

Post: Chairman of the Board

Employer: Chengdu Branch Office of Dalian Shantai Decoration Components Co., Ltd.

Tel: ××××××××

Business Entity Operated in China

Chengdu Branch Office of Dalian Shantai Decoration Components Co., Ltd.

Tax Authority in China: State Tax Administration, Xindu Dist., Chengdu City

Taxpayer S/N: ××××

Income Item

Period

Tax Payable

Tax Paid-in

Remark

Sales Income

Oct. ××××~Nov. ××××

×××,×××.××

×××,×××.××

Total

×××,×××.××

×××,×××.××

Statement of the Taxpayer

This is to declare that I have reported and paid the taxes according to Tax Law of P. R. China.

Taxpayer:×××××× (signed)

Dec. ××, ××××

Statement of the Tax Authority

This is to certify that, after verification, this business entity paid taxes of RMB ×××,×××.×× Yuan during Oct. ×××× to Nov.××××.

Authority: ××^th Sub-administration, State Tax Administration, Xindu Dist., Chengdu City (seal)

Dec. ××, ××××