EFTA01460133.pdf

Individual Self-Certification Form Part 1 - Individual Account Holder Information 1. Account Holder Name: Jeffrey Epstein 2. Date of Birth (mm/dd/yyyy): 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: If the Account Holder has additional countries of tax residence, please attach a statement to this form 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 may 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 related 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 hereto) is provided pursuant to the full terms and conditions governing the Account(s) and my contractual relationship with Deutsche 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 or the Account(s) now or in the future held with Deutsche Bank, to any relevant tax or governmental authorities of the country in which the Account(s) is/are/will be maintained or of any country in which I may be liable to pay taxes. I release 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 of such other countries may not afford the information the same protections which it receives in the country in which the Account(s) is/are/will 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 best of my knowledge and belief. correct and complete. I undertake to advise Deutsche Bank promptly of any change in circumstances which causes the information contained herein to become incorrect and to provide Deutsche Bank with a suitably updated Self-Certification within 30 days of such change in circumstances. Prig Name Authorized Signature Date (mm-c10-yyyy) 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. Internal Use Only Account Numbers): 35266976, 35269691, 680519, N4G024968 WM167633 023495 031516 Page 2 ot 2 CONFIDENTIAL — PURSUANT TO FED. R. CRIM. P. 6(e) DB-SDNY-0 121108 CONFIDENTIAL SDNY_GM_00267292 EFTA01460133