EFTA01460272.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 or each Controlling Person below. Please continue on a separate sheet if necessary (and attach to this form). Fest Name Rich Last Name Kahn Dare of Beth Can:offing Peron worspresidont Cant:NIlags, Country/Countries of Tax Resdence Panora US is Controlling Person a non-US Yes (complete Appendix 2) Beneficiary/non-US Beneficial Owner? ✓ No First Name J effrey Las' Name Epstein Oateof Con:rolling Person TypeiRola Director Bath 01120/1963 Conanling. country/counties of Tax Residence P•:rx;u US Virgin islands is Controlling P•11011 a non-US Yes (ararptete Appends 2) I No Benefictary/non US Beneficrai Owner'? First Name Erika LW Name Kellerhats Dal° cf Brat cc"m4"9 Person TypeRote Secretary, Director Ca4rahtng CountniCountries of Tox Resdence Paiszu . US Virgin islands is Conl/caing Person a non-US BenelicLuyinon-US Beneficial Omer? Yes (complea? Appendix No First Name Darren Last Name indyke Dale of 13irti Controlling Person Type,Role Treasurer, Director Controlling: County/Comings of Tax Residence Pon-nn US is Controteng Person a ncri-US BenefioaninenUS Beneficial Owner? Yes (complete Appendix 2) I No First Name Last Name Oats of Seth Controlling Person Type Role Congo1ring Country/Countries of Tax Resdence ?Nutt Is Controlling Person a non-US BeneSiaansnon-US Beneficial Owner? Yes (complete Append% 2) No Each Controlling Person who is also a non-US Beneficiary/non-US Beneficial Owner must complete and sign Appendix 2: Beneficlary/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. 141.1167679 023611.041516 Pugs Al CONFIDENTIAL - PURSUANT TO FED. R. CRIM. P. 6(e) DB-SDNY-0 121389 CONFIDENTIAL SDNY_GM_00267573 EFTA01460272