EFTA01345324.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-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 if necessary (and attach to this form). first Na.tIM Last Name_ Data el Brat COnffeartfi Pcioe TT"'Ree President CounifloCoundes of Tax Residence US Is Contrelling Person a non-US flenefetaryfron-US Beneficial Owner? Yes (comcsoteAimende 2i I No First Warne J e ffr ey La" Nora Epstein Dale of Birth Cm/I.:ding Ps3" TTPRIfin'" Director CalterYfOounten of lax R4140€04, US Virgin Islands Is Contoiling Person a non.US Yet (complete Appendix 2) J No BeneficiarylnoniUS Beneficial Owner' Pest Name- last Nemo Dale of Birt COrdrOlfing "OM^ fyriemelfl Secretary, Director Country(Countrais of Tax Residence US Virgin Islands Is Condoning Person a non-US Yes (=wine Appends 21 I to BenefiestyrnoreUS Benefifial Owner? First Nem Last Name Oahe of Birth Causing Munn TrDotl°41Treasurer, Director Country/Countries of Tax Residence US Is Ccedroling Person anon-US vas (complete appendix 2) No Berinearynon-US Beneficial OWIllf, feu Name LOM Name Date ot Owls Canoeing Pyson Ittaefffifie Couneatounisies of Tax Residence is Ccnirolling Person a non.US Yes fcctmotetc naPendix 21 Beneficiary/non-US Beioneal Owners NO 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. wm167679 023G f 154 Pepe Al CONFIDENTIAL - PURSUANT TO FED. R. GRIM. P. 6(e) DB-SDNY-0031598 CONFIDENTIAL SDNY_GM_00177782 EFTA01345324