EFTA01369667.pdf

Entity Self-Certification Form Appendix 1: Controlling Persons Appendix 1 must be completed for each Controlling Person of the entity, but only if the entity has a tax residence outside the United States. Please refer to the attached Guidance to the Entity Self-Certification Form which provides assistance for you to determine the Controlling Persons and how to complete this Appendix. Please provide details of each Controlling Person below. Please continue on a separate sheet it necessary (and attach to this form). Fest Mn Jeffrey Last Name Epstein of C°^" Img Pcrual TYPef" ° Pres., Dir., Ben. Owner Dal° Beth 01/20/1953 ConlnNl;ng Count:Swedes of Tax Residence Person US Virgin Islands is Controlling Person a non-US ✓ Yes (complete 4/M00ot 2) NO Bonentratyrnon.US sellersal Owner? Darren last Name lndyke Fall Da" DP10 of Birth Controlling Person TTPagalala Treas., Secy., Director Cannoning; Countiy/Countnes el Tax Residence Pere US Is Controling Person a non-US Yes (complete Appendix 2) i/ No geneficktryWorrUS Denefteel Owner? Fast Da" COC1Ift Lad Na" de Jongh Date of Controlling Person TY04111aale Director Coontn/(Countries of Tax Residence Penton US Virgin Islands Is Controlling Persona non-US BeneSsiary/non-US Elowectal Owner? Yes (complete Appende 2) ✓ No est Name Last NAOMI! Dale of /Inn Comrolling Person Type:Rote Conlr.).5I Country/Gamut ol Tax Residence Pprion Is Controlling Persona non-US Beneficiary/non.U$ Beneficial Clymer? Yes (complete Appendix 21 No Pest Heine Lost Name Date of Birth Controlling Person Typeillolo Control i no CcontrytCountnes of TeX Residence Person Is Controlling Person a non-US Yes (corneae. Appendix 2) No BeneficiarythonrJS BeneRcial Owner? Each Controlling Person who Is also a non-US Beneficiary/non-US Beneficial Owner must complete and sign Appendix 2: Beneficiary/Beneficial Owner Self-Certification Form. A Controlling Person who Is a Beneficial Owner with a tax residence solely In the United States Is not required to complete and sign Appendix 2. WMI61679 023611 041516 Page Al CONFIDENTIAL - PURSUANT TO FED. R. CRIM. P. 6(e) DB-SDNY-0062088 CONFIDENTIAL SDNY_GM_00208272 EFTA01369667