EFTA Document EFTA01298644

Deutsche Bank Wealth Management Entity Self-Certification Form Purpose of this Self-Certification Form Deutsche Bank AG and its affiliates (collectively. 'Deutsche Bank') collect certain information, Including tax relateo information, from their clients. Deutsche Bank collects this information to comply with ce.•tain local and international regulatory requirements that are designed, among other things, to foster and support a tax compliant environment. Although these requirements are not necessarily imposed by all countries. Deutsche Bank. as a global bank that strives to achieve consistency in its practices among all of Its regions. nonetheless requires this information be provided by clients even if not required by regulation. Accordingly. Deutsche Bank Wealth Management Americas rs writing to clients and sending you this Self•Certifiation to complete. This form is to be used in any situation where the Account Holder is an erieV. and not an individual, If in fact the Account Holder is an individual, the Individual should complete and provide the Individual Self-CerfificatIon Form which you can obtain by contacting your Deutsche Bank Wealth Management Americas Relationship Manager. Please note that a branch of an entity is treated as the entity for purposes of this Self•Certifiation and, therefore. the form Should be completed with details for the branch, and not the details of its parent. Please complete all sections below as directed and provide any additional information as may be required. For the purposes of this Self•Certifiation. -Account(s)- includes any accounts currently held with Deutsche Bank by the entity. White Deutsche Bank Wealth Management does not provide lax advice. you may contact your Relationship Manager if you have questions concerning the Self-Certification process. If you have any questions about how to complete this form or about how to determine your tax residency status, please refer to the attached Guidance to the Entity Self•Certifation Form, or contact your tax adviser cr local tax authority. The Haze Trust L4.931 Name 04' EAMy US Cooney or Ircofpcfacon of Ofearetaboo Entity's Country (Countries) of Tax Residence US Vigin Islands If Entity Account Holder is tax resident only in the United States, please proceed directly to Appendix 2 (which must be completed by each non•US Beneficiary and each non•US Beneficial Owner). If Entity Account Holder is tax resident outside the United States, please proceed to Part 2 and complete Appendix al and Appendix 2. Please insert the Legal Name of the Entity in Part l of Appendix 2. 1:051167679 023511041516 Page I of S SDNY_GM_00063553 CONFIDENTIAL - PURSUANT TO FED. RI taN Vej DENTIAL DB-SDNY-0026378 EFTA_00 1 7406 1 EFTA01298644 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 condole on a separate sheet If necessary (and attach to this form). Nar4 Jeffrey Data of Bin Ccuntry/Ccontries of Tax Residence US Virgin Islands Is Coma,!mg PC/1CA a nota./S BOnereClaryincn•US Benotaal Owner Feat Name Darren Dale or Bre CoulthletCounines of Tax ReNtYnCe US It Controlling Person a non.US Benoiciaryfnan.US Banetioal Owner at.l Name Due a Barth Counuyarconv es of Tax Res donee Is Conlsoihng Person a non.JS Beneboarenon-US Uncial Onnet7 Fest Name Data of 9.1!, CountryCounows of Tax Res.:Nees is Controlling Person a non.US Benef.ciary.bon.US Gent:Soar Darer, First Nome Date of Bah Cointy/CoanInes of Tax Residence Is Controang Person a ron•US Oanceiclaryffloa-US Denitaclal Oence7 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. ts'll Name Epstein Cadre" Pe' -P eatdeTrustorfTrustectameficiary Yee (co le Ayene e 2) teal "a" Indyke ControThrig Person TyoseRcle Trustee Ye, lcomplete Appendix 21 Last Name Contra., a Persr.n Type/Rola No No Yes (compete Apponla 2) Ab Last Nate CoraoGng PO11100 Tyr-Mole Yes (compiele accenex 2) NO Name Cenlrobieg Person Type:Rolm yes workologiAsesnox 21 No 1.V/416767g 023511041518 Page Al CONFIDENTIAL - PURSUANT TO FED. QQN 6(e) DENTIAL SDNY_GM_00063554 OB-SDNY-0026379 EFTA ()(1174062 EFTA01298645 if Non-US Bencificiary/Non-US Beneficial Owner is an Individual: 1. I hereby certify that for the purposes of taxation I am not a lax resident in any country other than the countrykountrhaS indicated above. 2. I confirm that my ownership or other interest in the Entity, if any, .S appropriately aisensed in accordance with applicable laws and regulations in the countries in which I am lax resident and may be required to be reflected in my tax filings. 3. I Genf rm that all Income or capital distributions received (or deemed to be receivec for tax purposes) by me from the Accounts) have been, and going forward will be, taken into account and included in my ielevant lax ffings if required by the laws of the country (countries) of my tax residence. If Non-US Beneficiary/Non-US Beneficial Owner s an entity: 1. I hereby certify that for the purposes of taxation the non-US Beneficiary/non-US Beneficial Owner is not a tax resident in any country other than the county/countries indicated in the self-certification. 2. I confirm that my ownership or other interest in the Entity, if any, is appropriately disclosed in accordance with applicable laws and regulations in the countries in which I am tax resident and may be required to be reflected in my tax filings. 3. I confirm that all income or capital distributions received (or deemed to be received for tax purposes) by me from the Account(s) have been. and will be. taken into account and included In the relevant tax filings if required by the laws of the country (countries) of tax residence. I agree that Deutsche Bank may disclose this Certification and any other information related to it or the Aocoun(s) now or in the future held with Deutsche Bank. to any relevant tax or governmental authorities of the country in which the Account(s) islareAvil be maintained or of any country in which I may be liable to pay taxes. I release Deutsche Bank from any obligations of bank secrecy, confidentiality and/or data protection under any applicable laws which might otherwise preclude the disclosure of such information. I acknowledge that the data protection laws of such other countries may not afford the information the same protections which if receives in the country in which the Account(s) istareAvill be maintained. I understand that this waiver will remain in force until cancelled and notwithstanding cancellation It cannot be terminated retroactively. I declare that all statements made in this Self-Certification are, to the best of my knowledge and belief. correet-and complete. I undertake to advise Deutsche Bank promptly of any change in *laminae s of which I a <e of and that causes the information contained herein to become incorrect and to ide Deutsche Ba we suitabl updated Certification within 30 days of such change in circumstances. Jeffrey Epstein Prim Name of Signer 04-28-2016 Cato Cron-nO myl CaPWAY NOW: Iraogricol O% WWI of an aolOY. please a•micate the capacity ;own ci you ate ggning pot example 'reales, Co-poralefrolsodual rnetcbt, ez.1 tonetbro • DPTE I 6-41-44 +•••••••••••••••••••OMISMS TIMP1• 7:"lrw -'1A-1, VERWIED NTERNAL USE ONLY Aecotec NLenheetst 2016 Deutsche Bank AG. Al ririts tosernd VAII67670 C236; I OTIS :6 pa,* An CONFIDENTIAL - PURSUANT TO FED. ?,IN Vej DENTIAL SDNY_GM_00063555 DB-SDNY-0026380 EFTA_00 174063 EFTA01298646 Deutsche Bank Wealth Management Client Risk Program --- Account Holder Name(s): erki- 1 44 - Cri S Account Number(s): Ultimate Beneficial Owner(s) (UBO), if different from Account Holder. Guideline This document is designed to assist the Relationship Manager (RM)/Investment Advisor (IA) in reviewing the certifications provided by the Account Holder, any Controlling Persons and any Ultimate Beneficial Owners as part of tho Client Risk Program. This form should be completed by the RM / IA and submitted together with the Self-Certification as described In the 'CRP Certification Form Submission' document. Before providing the Confirmation below, the following factors should be carefully considered: 1. Was any information in the Self-Certification provided by the Account Holder/UBO contradicted by, or Inconsistent with, information previously provided by the Account Holder/UBO to the RM IA? 2. Is the RM IA aware of any recent change in personal circumstances (e.g. domicile. residence, nationality) of the Account Holder/UBO without supporting documentation to verify the change having been provided to DB? If, after considering the factors above (or any other factors or information of which the RM / IA is aware), the RM / IA has reason to believe the Account Holder/UBO could be engaged in tax evasion, the RM / IA should not provide the confirmation below and should instead raise the matter with their supervisor. Relationship Manager/Investment Advisor (RM IA) Affirmation I confirm that I am not aware of any information that would lead me to conclude that the information provided in the Self-Certification is incomplete or inaccurate. I understand and acknowledge that if I become aware of any tax compliance concerns as it relates to the accounts listed above, I will promptly escalate the matter to my supervisor. eAni( /t4 t(« Responsible RM I IA Nome Cie — Dale For internal use only WM187534 023496.031516 CONFIDENTIAL — PURSUANT TO FED. C labl Vcol DENTIAL SDNY_GM_00063556 DB-SDNY-0026381 EFTA_00 174064 EFTA01298647