Code of Federal Regulations Title 22. Foreign Relations 22 CFR Pt. 240, App. A—APPLICATION FOR COMPENSATION

Ref:  Guarantee dated as of ___, 20_:

Gentlemen:  You are hereby advised that payment of $___ (consisting of $___ of principal, $___ of interest and $___ in Further Guaranteed Payments, as defined in § 240.02 of the Standard Terms and Conditions of the above-mentioned Guarantee) was due on ___, 20_, on $___ Principal Amount of Notes issued by Ukraine (the “Borrower”) held by the undersigned. Of such amount $___ was not received on such date and has not been received by the undersigned at the date hereof. In accordance with the terms and provisions of the above-mentioned Guarantee, the undersigned hereby applies, under § 240.08 of said Guarantee, for payment of $___, representing $___, the Principal Amount of the presently outstanding Note(s) of the Borrower held by the undersigned that was due and payable on ___ and that remains unpaid, and $___, the Interest Amount on such Note(s) that was due and payable by the Borrower on ___ and that remains unpaid, and $___ in Further Guaranteed Payments,  1 plus accrued and unpaid interest thereon from the date of default with respect to such payments to and including the date payment in full is made by you pursuant to said Guarantee, at the rate of ___% per annum, being the rate for such interest accrual specified in such Note. Such payment is to be made at [state payment instructions of Noteholder or Fiscal Agent, as applicable].

 In the event the Application for Compensation relates to Further Guaranteed Payments, such Application must also contain a statement of the nature and circumstances of the related loss.

All capitalized terms herein that are not otherwise defined shall have the meanings assigned to such terms in the Standard Terms and Conditions of the above-mentioned Guarantee.

[Name of Applicant]

By:  

Name:  

Title:  

Dated: