Samsung Semiconductor: transcript of exhibit 04 (page 1)
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Transcript
SAMSUNG SAMSUNG SEMICONDUCTOR, INC.
3655 North First Street
San Jose, CA 95134-1713
Tel (408) 544-4000
VENDOR DECLARATION FORM
Note: This Declaration shall be considered valid only if: (1) executed by a Controller, Accounting Manager,
CFO, or owner of Vendor; and (2) a handwritten or “wet” signature is used.
I, Errin O’Connor, having personal knowledge of the matters set forth herein, swear and affirm under
penalty of perjury as follows:
1. Iamcurrently employed at EPC Group (“VENDOR”), which is physically located at 4900 Woodway Dr
#830, Houston, TX 77056, and our company Tax ID Number En
2. I certify that my company’s remittance address is as follows:
4900 Woodway Dr #830, Houston, TX 77056
3. Ifmy company’s banking information has changed, | certify that the reason is forthe following:
O Company merger/acquired
O Company name change
O Fraud issue has occurred
O Other (please specify with detailed reason below):
eee
NA
4. Icertify that, by virtue of my employment and title at VENDOR, I have sufficient authority on VENDOR’s
behalf to provide VENDOR’s financialinformation to Samsung Semiconductor, Inc. (“SSI”).
5. I submit this Declaration in support of VENDOR’s release ofits bank details to facilitate VENDOR’s
lawful receipt of future EFT payment(s) from SSI.
6. Attached hereto are true and correct copies of an EFT Form and either a W-9 or W-8 Form completed and
executed by VENDOR’s appropriate authorized representative(s). I have verified that the EFI Form and
W-9 or W-8 Form contains VENDOR’s accurate and legitimate contact information and banking details.
I swear under penalty of perjury under the laws of the State of Califomia in the United States that the
foregoing information is true and correct. [REDACTED] [SIGNATURE REDACTED - ORIGINAL RETAINED BY EPC
[REDACTED] GROUP]
SIGNATURE: [REDACTED]
NAME (Print): [REDACTED]
JOB TITLE: GES
DATE: |}- 2Y-2od2s
Last Updated 10/06/2020
Se
O'Connor Enterprise Group, Inc., doing business as EPC Group, is the legal contracting entity for the engagements documented here.