EFTA01370181.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 of each Controlling Person below. Please continue on a separate sheet if necessary (and attach to this form). Fes Name Jeffrey Last Name Epstein Dal° °Deal 01/20/1953 C°^" Img Pecs" r s'Pef" ° Pres., Dir., Ben. Owner Centro+gag: CountryCouMrles of Tax Residence Pot US Virgin Islands Is Controlling Persona non-US Bonefinaryinon-US Elenercial Owner? ✓ Yes (oomplice 4/M00ot 2) NO First Darrell Last Name i nctyke Da" Data al Dia/102/19/1965 ColLecanD Person TYPollala Treas., Secy., Director ConCOMO Country/Coon/nes o! Tax Resedenoa Pinson L US Is Connoting Person a non-US Yes (complete Appendix 2) -/ No 6eneficaryrnanUS Benefigal Owner? Fist Name Cecile Laal N." de Jongh Dale of Beth 3/20/1962 Controlling Person TYPellaale Director GonersDin* Counb-sitountries of Tax Residence Penton US Virgin Islands Is Controlling Persona non-US Benensiary/non-US tileneenal Owner? Yes (complete Appendo 2) ✓ No dal Name Last NOM) Dale of /Inn Controlling Person Type:Role Conlog! Cooney/Countries of Tax Residence Parson Is ControAng Persona non-US BenendaryhectrUS Beneactal Clymer? Yes (cornolele Appendix 21 No PIN Name Lest Name Date of Barth Controlling Penton Traeger° Connor!' no Country/Countnes of TeX Residence Perina Is Controlling Person a non-US Yes {complete Paginate 2) No Benenciarygon-US Be ide:el Owner? 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. WM161679 023611 041516 Page At CONFIDENTIAL - PURSUANT TO FED. R. CRIM. P. 6(e) DB-SDNY-0062824 CONFIDENTIAL SDNY GM_00209008 EFTA01370181