EFTA01370185.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 detaas of each Controfling Person below. Please continue on a separate sheet it necessary (and attach to this form). Ant Name Je rey Name ff Lati Epstein Oats of Birth 01/20/1953 Controlling Person TypidRcle Trustor/Trustee/Beneficiary COT gf0:1111a Country/Countries of Tax Resdenee P0:14LI US Virgin Islands is Controlling Person a non-US .1 Yes (compkrie Appends No Benerroary/non.US Beneficial Owns!! Fiat Nome Darren " St NW" Indyke Dated Beth 02/19/1965 Controlling Person Type/Role Trustee Canto!!irx)}. Courey/Countros of Tax Resident* Parton US Is Controlling Person a non-US Benelidary/non-US Beneficial Avner? Yes (eeent ° APPender 2) I No First Name Las! Name Oats of Beth Controlling Person Type/Role Contrctrinsi 1:pentode-domain of Tax Residence denier, Is Command Person a non-US Yes (complete Appencitx 2) No Beneficianynon.US Beneficial Owner? Alt NINON Lag Name Dote ofBit. Controlling Person TypeiRole Country/CdunInedi of Tax Residence Controlling Person a non-US Benef.ciery/non.US Beneficial Owner? Yes (complete Appendix 2) No First Name Last Name Date or Bab Controlling Person Type/Role Cry:trolling Country/Countries of Tax Residence Parson Is Controlling Person a non.US BenelidarytnendlS Beneficial Oyster Yes (complete Appendix 2) No 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. WM167679 023611 041516 Page Al CONFIDENTIAL - PURSUANT TO FED. R. CRIM. P. 6(e) DB-SDNY-0062831 CONFIDENTIAL SDNY_GM_00209015 EFTA01370185