EFTA Document EFTA01345257

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 Conholing Person below. PleaSe Continue on a separate sheet if necessary (and attach to this form). fist Name Rich Data <4 Ea. C0MMIM Penes TY9ORCI. President CounarfOnantles of Tax Residence LAS! NstritKah n US Is Conlreare Pell e', a non-US Benefioaryfran-US Bentfical Owner First Wane J e ffrey Dale of Birl COMMYCOuntiket of Tax ReSalenee US Virgin Islands • Is Conflhing Person a non-US Benefckaryfnon.US Benefinal nano Finn Name Erika Dale Da CounfraCounIncis of Tar Realence US Virgin Islands Is Controlling Person a non-US BenefinatyrnereUS Benefgal Omar? FaSt Name Darren Dale of Si Cowin/It-aunties cil Tax Restarts, US Is Calming Persona non-US BenofearyMon-US Beneficial Owner, Flat Name Date of Dide Country/Counties of Tile ReSAlena• Yes (comerete Amanda 2i J No Last Nora Epstein Cm/I.:ding Pwrim' TSPRIRat" Director Yet (Comowe APpeadis 2) V No Yes (comelote rtooent Lag ""Kellerhals Controlling Panora rt,Pefftere Secretary, Director Last "" Indyke cavadie Pim"' ILTaCats Treasurer, Director Yes (romplet• acipendni 2) no LOA Name Canoeing Parson :neater* Is Centerline Person a noniUS Yes (tar piete AapentbX 2) NO SawfulfarylnOn-US Beemfmal Chimer, 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. wm167629 023;11 Of 1516 Pepe Al CONFIDENTIAL - PURSUANT TO FED. R. GRIM. P. 6(e) DB-SDNY-0031498 SDNY_GM_00177682 CONFIDENTIAL EFTA01345257