SMPC Disclosure Statement

Semirara Mining and Power Corporation

DISCLOSURE STATEMENT

(Supplement to the Conflict of Interest provisions per Code of Conduct)

1. Name ______________________________________________________

2. Position Title/Department _______________________________________

3. This statement is submitted (check one) :

¨  as an Annual Disclosure Statement (due every end of January together with the Code of Conduct Annual Certification), of my (non)financial interest* in contracts, sales, leases or purchases of Semirara Mining & Power Corporation &/or Subsidiary(ies), which are made on a regular basis with or from a particular contractor, customer or supplier; or

¨  as a "Single Transaction**" Disclosure Statement (due every time before a potential conflict of interest arises), of my financial interest* in a specific contract, sale, lease or purchase proposed to be entered into with Semirara Mining & Power Corporation &/or Subsidiary(ies) with or from a particular contractor, customer or supplier. Note: to be submitted to the President or Executive Vice President, prior to final action being taken on the contract, sale, lease or purchase.

*Includes any interest of myself, my spouse, in-laws, siblings, or child(ren).

**Transaction - (a) purchase, sale or lease of property of any kind, or (b) procurement of labor services, e.g. forwarding, catering, printing.

4. Are you or any member of your family have a direct or indirect interest in a business that buys, sells or leases property, goods or services to/from Semirara Mining & Power Corporation &/or Subsidiary(ies) ?   

                 Yes                              No

      If Yes, provide details (attach additional sheet as necessary):

          Contractor(s)/Supplier(s):  ___________________________________

          Nature: __________________________________________________

          Transaction reference or date/s _______________________________

          Transaction amount ________________________________________

5. In the past 12 months, have you received any compensation, loan (other than a bank loan at prevailing interest rate), gift, benefit or unusual hospitality from any customer, supplier, business partner or contractor of Semirara Mining & Power Corporation &/or Subsidiary(ies) ?

                               Yes                           No

           If Yes, provide details :  _____________________________________

6. Do you have any other business or personal relationships, not covered in your answers to preceding Questions that could appear to be a conflict of interest, time or undue influence to others in the organization or in the performance of your duties? When in doubt, disclosure is mandatory.   

                                    Yes                    No

         If Yes, provide details:_______________________________________

DECLARATION:

      I affirm the truth and completeness of this Disclosure Statement and to the best of my knowledge and belief is a true, correct and complete Statement of all my significant interests and other matters required by this disclosure. Also, I understand that failure to make proper disclosure as required may result in disciplinary actions.  Any changes to this Statement will be reported when the information becomes known to me.

I hereby agree to report promptly to the President, or Audit Committee, or Compliance Officer, or Legal Counsel as appropriate any situation or transaction that may arise during the year that constitutes a possible or potential conflict of interest and report the same on an amended Disclosure.

Printed Name/Signature  _____________________________________

Date:         __________________