SELF-DECLARATION OF THE BIOMASS GROWER REGARDING COMPLIANCE WITH SUSTAINABILITY CRITERIA 
according to the Part B Annex 4 Government Regulation No. 351/2012 on sustainability criteria for biofuels 
Unique identification number of the self-declaration:     

Issuer: 
     	Recipient1:
     	
1. Information about biomass:
Type:     
Year of harvest:      
Location of cultivation:      	
2. Information on the cultivation of biomass:
Biomass originates from cropland that was cropland prior to 1.1.2008.
                                                                            yes                                      no
Biomass was not cultivated in areas mentioned in § 2 sec. 4 - 6.
                                                                            yes                                      no
Biomass was cultivated in accordance with § 2 sec. 1 letter c).
                                                                            yes                                      no	
3. The greenhouse gas emissions production:
The greenhouse gas emissions production was determined using:
 disaggregated default values laid down in part C annex 1 
 actual values calculated in accordance with methodology laid down in part B annex 1 	

I declare that all information mentioned in this self-declaration of compliance with sustainability criteria is complete, accurate and truthful.

     
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Place and date of issue                                                                                 Signature