EFTA01370192.pdf

Entity Self-Certification Form Appendix 1: Controlling Persons Appendix :I 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 it necessary (and attach to this form). h I First " amJeffray 5. 141 Last Name Epstein Controlling Person Typefilolo Trustor Dele Bath 01/2011953 CounineCountries of Tax Residence US Virgin Islands is Controlling Persona non-US Beneflastylnon-US Beneficlal One? Yes (complete Append, 2) / No First Name Darren la nai" Indyke Data of Bei congaing Person TYPeinclie Trustee CourieWCountfies of Tex Resklence US is Confiding Parton, noodle Yes (complete Appendix 2) ✓ No tlenaloaryincin-US Beneacial Owner? nsi Wm Richard Last NameKahn Dab of fartn Controlling Person Type.Role Trustee Cooney/Cairene, of Tax Residence US Is Controlling Persona non-US Yes (cionetete Appendix 2) i No Elenencarytnon-US BeneSoial Cane*? First Name Mark 1a6t Nan. Epstein Dale of Beth Contrceng Person TypeRole Beneficiwy CoweviCountries of Tax Residence US Pe Conde tag Parson a noreUS Yes (complete Append* 2) / No Berialiciarylnon-US Beneficial Owner' First Name_ Lest Nene Dale of felre Controlling Paean Igpetttoki CountryCountrios of Tax Residence • Is Con:roan Person a non-US Yes (complete Appendix 2) Beneficieryfnon-US Banenciat Draw? Each Controlling Person who is also a non-US Beneficlarylnon-US Beneficial Owner must complete and sign Appendix 2: Beneficiary/Beneficial Owner SelfiCertification Form. A Controlling Person who Is a Beneficial Owner wtth a tax residence solely in the United States is not required to complete and sign Appendix 2. WIA161679 023111.041516 Page At CONFIDENTIAL - PURSUANT TO FED. R. CRIM. P. 6(e) DB-SDNY-0062841 CONFIDENTIAL SDNY_GM_00209025 EFTA01370192