EFTA01478405.pdf

Individual Self-Certification Form Part 1 - Individual Account Holder Information Jeffrey Epstein 1. Account Holder Name: 2. Date of Birth (mm/dd/yyyy): 1/20/1953 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: US Virgin Islands If the Account Holder has additional countries of tax residence, please attach a statement to this f orm 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 ma y 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 r elated 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 her eto) is provided pursuant to the full terms and conditions governing the Account(s) and my contractual relationship with Deuts the 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 o r the Account(s) now or in the future held with Deutsche Bank, to any relevant tax or governmental authorities of the cou ntry in which the Account(s) is/are/will be maintained or of any country in which I may be liable to pay taxes. I rele ase 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 o f such other countries may not afford the information the same protections which it receives in the country in wh ich the Account(s) is/are/wtil 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 b"st-effny-lqiowledge and^ beilef; complete. I undertake to advise Deutsche Bank promptly of any chafi^ in circumsfeiQc contained herein to become incorrect and to provide Deutsche Bpnk with a suit days of such change in circumstances. V Jeffrey Epstein X. Print Name 4-28-2016 Date (mm-dd-yyyy) I 1 Check this box if you are signing as a legal guardian for a minor or on behalf of an individual who lacks capacity to sign. cTand hlch causes the information dated Self-Certification within 30 Authorized Signatuis V Internal Use Only Account Numbers); Page 2 of 2 EFTA01478405