EFTA01357090.pdf

Entity Self-Certification Form Appendix 1: Controlling Persons Appendix 1must 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 seoarate sheet if necessary (and attach to this form). atria Hama Jeffrey tau Nam•Epsteln Dote of Elrlh ConIzoln-4 Perron TypoRole p-- res Dir., Ben. Owner 1/20/1953 CoonlrylCountnes of Tax Recioen« US Virgin Islands Is Control...ID Parson a non-US Tns (console* AOPenta 2: No Benefpcorylnon-tIs Bone:Wei Owners Fat Namo Darren l 'INNa"Indyke Dale of Perron eunIti" TWe' Rfle VP ,Secretary. Director CounfrytCoonoes o ax es nu US Is Con:Pang Person a non-US Yes (COIVelo AppervM 2) NO Elonefitiafyinon-US Beneficial Owners Nall Name Richard " IN "P. Kahn Duo of Cc41" .41)PerWmTwaitts Treasurer, Director CoviewCounves or Tax Residence US Is cosirowq Person a non-US .1 No Yes lOoneWe APO/ends 2) Benolidery-Mon-US Elepencal Owners First Name Iasi Name Oat. of Bulh Ceeeretreq Penns Type/Rote Counby/Crainines of Tax Residence Is Confolitno Person a non-US Yes (camplole A opendb 2) NO BenefIcInynsoft-US Benenefal Owners First Nan* to t Name Dale el Beth Corlroten Person Type/Role Countnr/COuntnes of fax Re-science N Contitihno Person a nen-US Yes (neromme Apoecnor 2) NO eanernistymen-US Sanerntei Owner? Each Controlling Person who Is also a non-US Beneficiary/non-US Beneficial Owner must complete and sign Appendix 2r 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. WM167679 0236(1 041516 Pool Al CONFIDENTIAL - PURSUANT TO FED. R. GRIM. P. 6(e) DB-SDNY-0043406 CONFIDENTIAL SDNY_GM_00189590 EFTA01357090