EFTA01478116.pdf

Individual Self-Certification Form Deutsche Bank AG and its affiliates (collectively, "Deutsche Bank") collect certain information, including tax related information, from their clients. Deutsche Bank collects this information to comply with certain local and international regulatory requirements that are designed, among other things, to foster and support a tax compliant environment. Although these requirements are not necessarily imposed by all countries, Deutsche Bank, as a global bank that strives to achieve consistency in its practices among all of its regions, nonetheless requires this information be provided by clients even if not required by regulation of the country where your account is maintained. Accordingly, Deutsche Bank Wealth Management Americas is sending you this three-part Self-Certification to complete. This Self-Certification applies only to Account Holders who are individuals. If you are an Account Holder but you are not an individual (for example, you represent a corporate entity, personal investment company, trust or other entity) and you received this Self-Certification in error, we ask that you contact your Deutsche Bank Relationship Manager so that we can provide you with the appropriate Entity Self-Certification Form for you to complete. As the Account Holder, you are required to state your residency (or residencies) for tax purposes. If you are a tax resident outside the United States, then Deutsche Bank may be required to report the relevant information on this Self-Certification to the appropriate tax authorities. For joint or multiple Account Holders, please complete a separate Self-Certification for each Account Holder. Please complete the sections on page 2 as directed and provide any additional information as may be required. For the purposes of this Self-Certification "Account(s)" includes any accounts currently held in your name at Deutsche Bank, as well as any accounts you open in the future that are held at Deutsche Bank. While Deutsche Bank Wealth Management does not provide tax advice, you may contact your Relationship Manager if you have questions concerning the Self-Certification process. If you have any questions about how to complete this SelfCertification or about how to determine your tax residency status, please contact your tax adviser or local tax authority. WM167633 023495.031516 Page 1 of 2 EFTA01478116 Individual Self-Certification Form Part 1 — Individual Account Holder Information I. Account Holder Name: 2. Date of Birth (mm/dd/yyyy): Part 2 — Tax Residency and Tax Compliance Status For the purposes of taxation, I am a tax resident of the following country/- countries: Country of Tax Residence: If the Account Holder has additional countries of tax residence, please attach a statement to this form containing the required information outlined above. I hereby certify that for the purposes of taxation I am not a tax resident in any country other than the country/countries indicated above. I am aware that income deriving from the Account(s), as well as related transactions, may trigger a tax liability in accordance with applicable laws and regulations in the countries in which I am a tax resident and may be required to be reflected in my tax filings. I confirm that all assets held with Deutsche Bank Wealth Management, as well as any and all income related thereto, where applicable, have been, and going forward will be, taken into account and included in my relevant tax filings when determining my tax obligations. Part 3 — Declaration and Signature I understand that the information supplied by me in this Certification (including any attachment hereto) is provided pursuant to the full terms and conditions governing the Account(s) and my contractual relationship with Deutsche Bank setting out how Deutsche Bank may use and share the information supplied by me to Deutsche Bank. I agree that Deutsche Bank may disclose this Certification and any other information related to it or the Account(s) now or in the future held with Deutsche Bank, to any relevant tax or governmental authorities of the country in which the Account(s) is/are/will be maintained or of any country in which I may be liable to pay taxes. I release Deutsche Bank from any obligations of bank secrecy, confidentiality and / or data protection under any applicable laws which might otherwise preclude the disclosure of such information. I acknowledge that the data protection laws of such other countries may not afford the information the same protections which it receives in the country in which the Account(s) is/are/will be maintained. I understand that this waiver will remain in force until cancelled and notwithstanding cancellation it cannot be terminated retroactively. I declare that all statements made in this Self-Certification are, to the best of my knowledge and belief, correct and complete. I undertake to advise Deutsche Bank promptly of any change in circumstances which causes the information EFTA01478117 contained herein to become incorrect and to provide Deutsche Bank with a suitably updated Self-Certification within 30 days of such change in circumstances. Print Name Date (mm-dd-yyyy) llCheck this box if you are signing as a legal guardian for a minor or on behalf of an individual who lacks capacity to sign. Internal Use Only Account Number(s): Authorized Signature WM167633 023495.031516 Page 2 of 2 35266976, 35269691, 680519, N4G024968 Jeffrey Epstein EFTA01478118