EFTA01369090.pdf

DECLARATION OF STATUS FOR ISRAELI INCOME TAX PURPOSES (This declaration should be completed only by Non-Israeli Residents and Israeli Brokers.) You are retching this form "Declaration of Status for Israeli Income Tax Purposes" as a holder of Ordinary Shares, nominal value €0.01 per share, per share (the "Shares") of Mobileye N.V. (the "Company"), in connection with the tender offer. By completing this form in a manner that would substantiate your eligibility for an exemption from Israeli withholding tax, you will allow paying agent, Israeli withholding tax agent, your broker or any other withholding agent, or their authorized representatives to exempt you from Israeli withholding tax. PART I , Identification and details of Shareholder (including Eligible Israeli Broken) (see instructions) 1. Name: 2. Type of Shareholder (more than one box may be applicable): (please print full name) Q.Pe Corporation (or O Bank Limited Liability O Broker Sc LI Ikc re. n n of. L.t GI L Lc Company) 0 Individual O Financial Institution 0 Trust 0 Partnership 0 Other: 3. For individuals only: 4. For all other Shareholders Date of birth: / / Country of incorporation or organization: month/ day / year 11 S. V .'rrtin \s‘O.ni13 Country ofresidence: Registration number of corporation (if applicable): Countries of citizenship (name all citizenships): Car p. No. St3Wci Taxpayer Identification or Social Security No. (if applicable): Country ofresidence: Li . S. Iii. ; rki 4n. IS 1O eal 5. Permanent Address (state, city, zip or postal code, street, house number, apartment number): (n1OO V, c d tiook a ctori-cr IV'S . g k .Thorfas USVI OO7(Y.2 6. Mailing Address (if different from above): 7. Contact Details: Name: ki, kor el Kok; Capacity: - Telephone Number (country code, area co e an num er : 8.1hold the Shares of the Company (mark X in the appropriate place): O directly, as a Registered Holder raihrough a Broker. If you marked this box, please state the name of your Broker bc,LV5C k a Ric.r.1- 9. 1hold less than 5% of the Company's issued shares. Yes fi No O CONFIDENTIAL - PURSUANT TO FED. R. CRIM. P. 6(e) DB-SDNY-0061176 CONFIDENTIAL SDNY_GM_00207360 EFTA01369090