EFTA01369485.pdf

Deutsche Bank Self Certification for Entity Clients UK Automatic Exchange of Information and the OECD Common Reporting Standard (CRS) Part 4 - Country of Residence for Tax Purposes and related TIN or functional equivalent Please complete the following table indicating (0 where the Account Holder is tax resident and (10 the Account Holders TIN for each country indicated. If the Account Holder is not tax resident in any jurisdiction (e.g.. because it is fiscally transparent), please indicate that on line 1and provide its place of effective management or country in which its principal office is located. It the Account Holder Is tax resident in more than three countries please use a separate sheet. If a TIN is unavailable please provide the appropriate reason A, B or C where appropriate: Reason A The country where tarn liable to pay tax does not issue 71Ns to its residents, Reason B - The Account Holder is otherwise unable to obtain a TIN or equivalent number. (Please explain why you are unable to obtain a TIN in the below table if you have selected this reason.) Reason C - No TIN is required. (Note: only select this reason if the authorities of the country of tax residence entered below do not require the TIN to be disclosed.) to. Country of Tax 11. Specified 12. Local Tax Identification 13. TIN Type 14, If no TIN available enter Residence' Person?' Number MN) Reason A. B or C • Please explain in the following boxes why you are unable to obtain a TINIf you selected Reason B above. 2 ❑ 15. I certify that for the purposes of taxation the Account Holder Is not Tax Resident in any other country other than the countries indicated in Part 4 above. Part 5 — Declaration and Signature I understand that the information supplied by me in this Certification (Including any attachment hereto) is covered by the fu:{ provisions of the terms and conditions governing my/the Account Holders relationship with Deutsche Bank setting out how Deutsche Bank may use and share the information supplied by me to Deutsche Bank. I acknowledge and agree that the Information contained in this Certification (including any attachment hereto) and information regarding the Account Holder may be reported to the tax authorities of the country in which this accounts) is/are maintained end exchanged with tax authorities of another country or countries in which the Account Holder may be tax resident where those countries (or tax authorities in those countries) have entered into Agreements to exchange financial account information with the country/ies In which this account$) is/are inaMtained. I declare that all statements made in this Certification are, to the best of my knowledge and belief, coned 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 Certification Within 30 days of such change in circumstances. liPlease check this box to confirm that you have the capacity to sig the accounts to which this form relates. Print Name-. ciTr-t1 Ep5\c,,n Date (dcl/rnm/yyyyr: 11In.I oar? CONFIDENTIAL - PURSUANT TO FED. R. CRIM. P. 6(e) DB-SDNY-0061768 CONFIDENTIAL SDNY GM_00207952 EFTA01369485