EFTA Document EFTA01369090

DECLARATION OF STATUS FOR ISRAELI INCOME TAX PURPOSES (This declaration should be completed only by Non-Israeli Residents and Israeli Brokers.) You are retching this form "Declaration of Status for Israeli Income Tax Purposes" as a holder of Ordinary Shares, nominal value €0.01 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 wit