EFTA01383714.pdf

INSTRUCTIONS FORMING PART OF THE DECLARATION OF STATUS FOR ISRAELI INCOME TAX PURPOSES I. General Instructions. This Declaration Form (Declaration of Status for Israeli Income Tax Purposes), or this Form. should be completed by holders of Shares who wish to tender their Shares pursuant to the Offer, and who are either: (i) Non-Israeli Residents: (I) hold less than 5% of the outstanding Shares of Mobikye, (2) NOT "residents of Israel" for purposes of the Ordinance (See Instruction II below), and (3) DID acquire the Shares tendered on or after January I, 2009; or (ii) A Bank. Broker or Financial Institution Resident in Israel: a bank. broker or financial institution that are "residents of Israel" within the meaning of that tenn in Section 1 of the Ordinance, that (I) is holding Shares solely on behalf of beneficial shareholders) who holds less than 5% of the outstanding Mobileye shares and acquired his Mobileye shares on or after January• I. 2009 (so-called "street name" holders), and (2) is subject to the provisions of the Ordinance and the regulations promulgated thereunder relating to the withholding of Israeli tar including with respect to the cash payment (if any) made by them to such beneficial sharcholder(s) with respect to Shares tendered by them and accepted for payment by Mobileye pursuant to the Offer (an "Eligible Israeli Broker"). NOTE: AN ELIGIBLE ISRAELI BROKER MAY COMPLETE THIS FORM IF IT IS HOLDING THE SHARES SOLELY ON BEHALF OF HIS CLIENTS, THE BENEFICIAL SHAREHOLDERS. Part I (Identification and details ofShareholder, including Eligible Israeli Broker). You should complete Item I. 2 and 5 through 8 and either (i) Item 3, if you are an individual, or (ii) Item 4, if you are a corporation (or limited liability company), mist, partnership, bank broker, financial institution or other entity. If you hold less than 5% of the outstanding Shares of Mobileye, you should complete Item 9. Part II (Declaration by Non-Israeli Residents). If you are NOT an Israeli resident, and acquired the Shares tendered on or after January 1, 2009, you should complete either Section A (for Individuals). Section B (for Corporations). Section C (for Partnerships) or Section D (for Trusts). If you do not mark a box you will be deemed to answer that the corresponding item is not correct with respect to you. Part III (Declaration by Israeli Bank, Broker or Financial Institution). If you are an Eligible Israeli Broker, you should mark the box in this Part. PartIV (Certification) and Signature Block. By signing this Form you also make the statements in Part IV. Inadequate .Space. If the space provided on this Form is inadequate, you should insert such details on a separate signed schedule and attached to this Form. Determination of Validity. All questions as to the validity, form or eligibility (including time of receipt) of this Form will be, subject to applicable law, determined by Purchaser. in its sole discretion. None of Purchaser. the U.S. Depositary, the Information Agent or any other person will be under any duty to give notification of any defects or irregularities in any Fonn or incur any liability for failure to give any such notification. For more details, see Section 5 of the Offer to Purchase. Questions and Requestsfor Assistance or Additional Copies. Questions and requests for assistance may be directed to the Information Agent at the address or telephone numbers set forth on the back cover of the offer to purchase. Additional copies of this Fenn may be obtained from the Information Agent. The method of delivery of this Form is at your option and risk, and the delivery will be deemed made only when actually received by your Broker or the Depositary. If delivery is by mail, registered mail with return receipt requested, is recommended. In all cases, sufficient time should be allowed to ensure timely delivery. No alternative, conditional or contingent Forms will be accepted. 4 CONFIDENTIAL - PURSUANT TO FED. R. CRIM. P. 6(e) DB-SDNY-0083509 CONFIDENTIAL SDNY GM_00229893 EFTA01383714