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Translation Appendix 4APro-forma capital verification report (example provided by CICPA)Capital Verification Report To Company nameWe accepted the appointment to examine the second installment of registered capital contribution of Company name (“the Company”) as at date in respect of its application for incorporation and registration. The responsibilities of all its investor(s) and the Company are to ensure that the capital contributions comply with the legal requirements of the relevant laws, regulations, agreements, contracts and articles of association; to provide true, legitimate and complete information for the verification of capital contributions and to safeguard the Companys assets. Our responsibility is to express an opinion on the second installment of capital contribution in accordance with the “Statement of Independent Auditing Practices No.1: Verification of Capital Contribution”. In the course of our examination, we performed examination procedures as we considered necessary in the circumstances.According to the agreements, contracts and articles of association, the Companys registered capital to be contributed by name (Party A) and name (Party B) is currency amount and shall be fully contributed in number installments prior to date. The current contribution is for the second installment, which shall be contributed before date. Based on our examination and as at date, the Company had received capital contribution of currency amount contributed by Party A and Party B. The aforesaid actual capital contribution currency amount is in the form of cash, currency amount is in the form of tangible assets, and currency amount is in the form of know-how. The capital contributed in the form of know-how accounts for % of the registered capital.In addition, we also noted that the first installment of registered capital contribution of the Company, currency amount, of which currency amount was contributed by Party A and currency amount was contributed by Party B, was verified by name Certified Public Accountants Co., Ltd. with capital verification report (number of report) issued on date. As at date, the Company has received accumulated capital contribution of currency amount in total.This Capital Verification Report is for the use of the Company to apply for its incorporation and registration and to issue investment certificate(s) to the investor(s). It is not to be deemed as a guarantee or an assurance of the Companys abilities in maintaining capital, repaying debts or operating as a going concern. XXXX Certified Public Accountants and the Certified Public Accountants who performed this verification shall not be hold liable for any consequences caused by the misuse of this Capital Verification Report.Appendix I Summary of the Second Installment of Capital ContributionAppendix IISummary of Accumulated Capital ContributionAppendix IIINotes to Capital Verification ReportXXXX Certified Public AccountantsCertified Public Accountant Certified Public Accountant Shanghai, the Peoples Republic of ChinadateAppendix ISummary of Second Installment of Capital ContributionAs at dateCompany name: Name of currency in which registered capital is expressed:Monetary unit:Name of Investor (s)Registered capital subscribed for the current installmentThe current installment of capital contributionCashTangible AssetsIntangible AssetsOthersTotal(expressed in the currency of registered capital)Including: actual capital contributionAmount Proportion to total capital subscribedOriginal currencyEquivalent of the currency in which the registered capital is expressedOriginal currencyEquivalent of the currency in which the registered capital is expressedOriginal currencyEquivalent of the currency in which the registered capital is expressedName of accounting firm performing the capital verification: (Chop)Certified Public Accountant: (Chop)Certified Public Accountant: (Chop)Appendix IISummary of Accumulated Capital ContributionAs at date Company name: Name of currency in which registered capital is expressed:Monetary unit:Name of Investor(s)Registered CapitalAccumulated CapitalContribution Brought ForwardCurrent Installment of Capital ContributionAccumulated Capital Contribution Carried ForwardAmountProportion to Total Registered CapitalAmountProportion to Total Registered CapitalAmountProportion to Total Registered CapitalAmountProportion to Total Registered CapitalName of accounting firm performing the capital verification: (Chop)Certified Public Accountant: (Chop)Certified Public Accountant: (Chop)Appendix IIINotes to Capital Verification Report1.Information on approval and establishment of the Company The Company was jointly established by Party A and Party B under approval by competent authority evidenced by approval document year No. number. Its certificate of approval was issued by name of issuing entity on date and numbered number. The Company obtained the business license on date which is issued by Administration of Industry and Commerce. The registration number is number. 2.Registered capital and its terms of contributionIn accordance with the approved agreements, contracts and articles of association, the Companys registered capital is currency amount. The registered capital shall be fully contributed by the investors in number installments before date. The current capital contribution is for the second installment. Party A shall contribute currency amount, which accounts for % of the registered capital, currency amount of the contribution is contributed in the form of cash, currency amount is contributed in the form of tangible assets and currency amount is contributed in the form of know-how; Party B shall contribute currency amount, which accounts for % of the registered capital, currency amount of the contribution is contributed in the form of cash, currency amount is contributed in the from of tangible assets. 3.Results of verificationAs at date, the Company had received the second installment of capital contribution of currency amount. i) Party A contributed currency amount in the second installment, of which currency amount was remitted to the Companys currency capital bank account (a/c No.) on date; know-how valued at amount was contributed on date, the value of which, as determined by all investors, is amount;Appraisal of the know-how contributed by Party A has been performed by Name of asset appraisal firm with an asset appraisal report issued thereon. Party A has signed a technology transfer contract with the Company in connection with the aforesaid know-how and the property transfer procedures have been completed.ii) Party B contributed currency amount in the second installment, of which currency amount was remitted to the Companys currency capital bank account (a/c No.) on date; tangible assets (name, quantity etc. were contributed on date, the value of which is determined at amount. The determined value has been confirmed by Administration of Quality Inspection and Quarantine of province with Property Value Confirmation number of certificate issued. (The currency referred to above is the currency in which registered capital is expressed. If currency in which capital is actually contributed differs from that in which registered capital is expressed, the following items should be disclosed: name of original currency and amount in that original currency; exchange rate(s) adopted; equivalent amount in the currency in which registered capital is expressed)(If amount actually contributed by the investor(s) exceeds its (their) capital subscription for the current installment, the treatment of the excess should be disclosed.)4. Other matters2.XXXX有限责任会计师事务所XX所【2004】X验字18号验资报告XXXX Accountant Office FirmXX X Yan Zi No.18, 2004Capital VerificationOOO医疗器械有限公司(筹)全体股东:All shareholders of OOO Medical Instruments Co., Ltd (in preparation period):我们接受委托,审验了贵公司(筹)截至2004年4月1日止申请设立登记的注册资本实收情况。按照国家相关法律、法规的规定和协议、章程的要求出资,提供真实、合法、完整的验资资料,保护资产的安全、完整是全体股东及贵公司(筹)的责任。We accepted the appointment to verify the paid-in capital to be applied for registration of OOO Medical Instruments Co., Ltd (in preparation period and hereinafter abbreviated as Company) to April 1, 2004. The responsibilities of the Company and its all shareholders are to invest in accordance with the requirements of agreement and the articles of the association of the Company and the provisions of related laws and codes of the state, and provide true, legitimate and complete information for capital verification, and ensure the safety and completeness of its assets. 我们的责任是对贵公司(筹)注册资本的实收情况发表审验意见。我们的审验是依据独立审计实务公告第1号一一验资进行的。在审验过程中,我们结合贵公司(筹的实际情况,实施了检查等必要的审验程序。Our responsibility is to issue a verification opinion on the Companys paid-in registration capital. Our verification is in accordance with “Statement of Independent Auditing Practices No.1: Verification of Capital Contribution”. In the verification, in consideration of the Companys practice, we carried out necessary audit and verification procedures.根据有关协议、章程的规定,贵公司筹申请登记的注册资本为人民币50万元,由XX(以下简称甲方、XXX(以下简称乙方出资缴足。经我们审验,截至2004年4月1日止,贵公司筹己收到全体般东缴纳的注册资本合计人民币伍拾万元整(¥500,000元) ,各股东以货币出资。As stipulated in related agreement and the articles of the association, the registered capital of the Company in application for its registration is RMB 500,000 Yuan, which shall be invested by XXX (hereinafter abbrevia
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