EFTA01369678.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). First NangiJOffraY Last Name Epstein 14 of Br) 01120/1953 Convening Person TypeiRole Trustor 9 Dale Counlrynounines of Tax Residence iNy US Virgin Islands le Controsing Person a non-US 44 Benallastehon-US Beneficial Omer? Yes (complete Appendix 2) 4/ No Fat Name Darren tat Indyke Dale oil BIM v i enees CortIroang Person Typsaiolo Trustee CourswiCouninut ot In Passim US Is Confiding Person a non.US I No Benegoaryhson-US Beneficial Omer? Yes (comply* Appendix 2) Lae& Name Kahn PmNameRichard Controlling Person Typeflole /hates Dale °Seth 12/06/1972 cassava:Rimers at Tax Residence US Is Controlling Person* non-US Yes {conelea Apperata 2) No Bteenclecifnen-US Bet Owner? Fast Name Mark Last Name Epstein controlling Person TwieRole Beneficiary an cif Bill 7/14/1954 Cotetyltountaes of Tax Residence US ts Conde/Re Parson a non.US No Berierciarylnon-US Beneficial Owner? Yes (complete Append* 2) Fes Name ca ne La g NW/. Dubin DateatBirth3/31/1995 Controlling Poem PIPWRole Beneficiary CouttyCountries of Tax Residence US Is Convolimg Persona non-US .0' No Beneficiary/non-US Benefice' Omer? Yea (compete Appendix 2) 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 wtth a tax residence solely in the United States is not required to complete and sign Appendix 2. WM161679 023111.041516 Page At CONFIDENTIAL - PURSUANT TO FED. R. CRIM. P. 6(e) DB-SDNY-0062103 CONFIDENTIAL SDNY_GM_00208287 EFTA01369678