EFTA01460218.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-CertlficatIon 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). Pot Name Jeffrey Lett Name Epstein Dale of Binh 01/20/1953 Controlling Person Type/Role Sole Member COlittlAng: Country/Countries of Tax Residence US Virgin Islands is Controlling Persona non-US Yes (comp:tie Appeede 2) No Beneficiary/non-US Beneficial °emir? First Name Larry Last Nan° Visoski Date of Sot Conetamg Person Type:Role Manager Cant/1,101z County/Countnee ol Tax Residence Emmen ' US Is Cootroang Person • non-US Yes foompleta Appendix 2) BeneficsaryThon-US Benefiewl Owner? st No FIRM Name LOS, Name Crate of Bain Centro/ling Porson TypeiRote COMIV tan Counity/CouNriat of Tax Reredento roan Is Unending Person a non-US Yes (comets-la Append/1 2) No Beneficiary/non4)S BeneNgai Owner? First Name Last Name Oat of BtrIh Conlrolng Person Type/Rohn Centrenig Couney/Coantrans el Tax Residence Pam on Is Coalman° Person a non.US Yes focenplele Appendix 2) No BenalScraryffice-US Benetclal Owner? Fest Name Last Notre Date of Sem Controaing Person Type/Rote Contra/ Country/Countries of Tax Residence Panr,n Is Controlling Person a non•US Yes (ysmpeste Appendix 2) No Beneficiary/non-US Beneficial 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. WMI676/1 023611441516 Page At CONFIDENTIAL - PURSUANT TO FED. R. CRIM. P. 6(e) DB-SDNY-0121279 CONFIDENTIAL SDNY_GM_00267463 EFTA01460218