EFTA Document EFTA01370192

Entity Self-Certification Form Appendix 1: Controlling Persons Appendix :I 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 it necessary (and attach to this form). 5. h I First "amJeffray 141 Dele Bath 01/2011953 CounineCountries of Tax Residence US Virgin Islands is Controlling Persona non-US Beneflastylnon-US Beneficlal One? First Name Darren Data of Bei CourieWCountfies of Tex Resklence US is Confiding Parton, noodle tlenaloaryincin-US Beneacial Owner? nsi Wm Richard Dab of fartn Cooney/Cairene, of Tax Residence US Is Controlling Persona non-US Elenencarytnon-US BeneSoial Cane*? First Name Mark Last Name Epstein Controlling Person Typefilolo Trustor Yes (complete Append, 2) / No la nai" Indyke congaing Person TYPeinclie Trustee Yes (complete Appendix 2)  No Last NameKahn Controlling Person Type.Role Trustee Yes (cionetete Appendix 2) i No 1a6t Nan. Epstein Dale of Beth Contrceng Person TypeRole Beneficiwy CoweviCountries of Tax Residence US Pe Conde tag Parson a noreUS Berialiciarylnon-US Beneficial Owner' First Name_ Dale of felre CountryCountrios of Tax Residence • Is Con:roan Person a non-US Beneficieryfnon-US Banenciat Draw? Yes (complete Append* 2) Lest Nene Controlling Paean Igpetttoki Yes (complete Appendix 2) / No Each Controlling Person who is also a non-US Beneficlarylnon-US Beneficial Owner must complete and sign Appendix 2: Beneficiary/Beneficial Owner SelfiCertification Form. A Controlling Person who Is a Beneficial Owner wtth a tax residence solely in the United States is not required to complete and sign Appendix 2. WIA161679 023111.041516 Page At CONFIDENTIAL - PURSUANT TO FED. R. CRIM. P. 6(e) DB-SDNY-0062841 CONFIDENTIAL SDNY_GM_00209025 EFTA01370192