EFTA01369861.pdf

DECLARATION OF STATUS FOR ISRAELI INCOME TAX PURPOSES (This declaration should he completed only by Non-Israeli Residents and Israeli Brokers.1 You arc receiving this form "Declaration of Status for Israeli Income Tax Purposes" us a holder of Ordinary Shares, nominal value €0.011 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. ART I Identification and details of Shareholder (including Eligible Israeli Brokers) (see instructions) 1. Name: 2. Type of Shareholder (mom than one box may be applicable): (please print full name) ❑ Corporation (or ❑ Bank Limited Liability O Broker Company) O Financial Institution ❑ Individual ❑ Trust O Partnership O Other 3. For individuals only: 4. For all other Shareholders Date of birth: / / Country of incorporation or organization: month/ day / year Country of residence: Registration number of corporation (if applicable): Countries of citizenship (Mame all citizenships): Taxpayer Identification or Social Security No. (if applicable): Country of residence: 5. Permanent Address (state, city, zip or postal code. street house number, apartment number): 6. Mailing Address (if different from above): 7. Contact Details: Name: Capacity: Telephone Number (country- code. area code and number): S. I hold the Shares of the Company (mark X in the appropriate place): O directly, as a Registered Holder O through a Broker. If you marked this box, please state the name of your Broker: 9. I hold less than 5% of the Company's issued shares. Yes ❑ No ❑ CONFIDENTIAL - PURSUANT TO FED. R. CRIM. P. 6(e) DB-SDNY-0062362 CONFIDENTIAL SDNY GM_00208546 EFTA01369861