EFTA Document EFTA01478336

EFTA01478336 EFTA01478337 EFTA01478338 EFTA01478339 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 related information, from their clients. Deutsche Bank collects this information to comply with certain 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 is writing to clients and sending you this Self-Certification to complete. This form is to be used in any situation where the Account Holder is an entity, and not an individual. If in fact the Account Holder is an individual, the individual should complete and provide the Individual Self-Certification 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-Certification 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-Certification, "Account(s)" includes any accounts currently held with Deutsche Bank by the entity. While Deutsche Bank Wealth Management does not provide tax 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 foim or about how to determine your tax residency status, please refer to the attached Guidance to the Entity Self-Certification Form, or contact your tax adviser or local tax authority. P^ft.lA ! Entity Account Holddr Mort, Inc Legal Name of Entity US Virgin Islands Countiy of Incon^oration or Organization PartlB lEh96Taxf^si9en^ M'S EFTA01478340 Entity's Country (Countries) of Tax Residence us Virgin 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 1 and Appendix 2. Please insert the Legal Name of the Entity in Part 1 of Appendix 2. WM167679 023611.041516 Page 1 of 5 Part 2 I Deciaratibn and Signature I understand that the information supplied by me in this Self-Certification (including any attachment hereto) is provided pursuant to the full terms and conditions governing the Account and the Account Holder's contractual relationship with Deutsche Bank setting out how Deutsche Bank may use and share the information supplied by me to Deutsche Bank. I agree that Deutsche Bank may disclose this Self-Certification and any other information related to it or the Accounts) now or in the future held with Deutsche Bank, to any relevant tax or governmental authorities of the country in which the Account(s) is/are/wlil be maintained or of any country in which the Account Holder 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 it receives in the country in which the Account(s) is/are/will be maintained. I understand that this waiver will remain in force until cancelled and notwithstanding cancellation it cannot be terminated retroactively. I declare that the below statements are, to the best of my knowledge and belief, correct and complete: 1. I hereby certily that for the purposes of taxation the Account Holder is not a tax resident in any country other than the country/countries indicated In this Self-Certification. 2. I am aware that income deriving from the Account(s), as well as related transactions, may trigger a tax liability in accordance with applicable laws and regulations and that this may be reflected in the Account Holder's tax reporting. 3. i confirm that all assets held by the entity with Deutsche Bank Wealth Management, as well as any and all income and gains related thereto, where applicable, have been, and will be, taken into account and included in the relevant tax filings as required by the laws of the country(countries) of tax residence. EFTA01478341 1 declare that all statements made and information contained in this Self- Certification (including the information in Appendix 1 and Appendix 2, as applicable) are, to the best of my knowledge and belief, correct and complete. I undertake to advise Deutsche Bank promptly of any change in circumstances of which I am aware of and that causes the information contained herein to become incorrect and to provide Deutsche Bank with a suitably updated Self-Certification within 30 days of such change. I further certify that I am duly authorized to sign for this Account Holder and to provide all the confirmations herein with respect to all the Account(s) to which this Self-Certification relates. Darren Indyke Print Name IL 04-28-2016 Data (mm-<jd>yyyy) Secretary Capacity Note: Please indicate the capacity in which you are signing the form (for example Trustee, Corporate/Individual Director, etc.) Account Number(s): INTERNAL USE ONLY: WM167679 023611.041518 Page 2 of 5 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. Piease 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. Piease provide details of each Controlling Person below. Please continue on a separate sheet if necessary (and attach to this form). 1 First Name Last Name Jeffrey Date of Birth 953 Epstein Controlling Person Type/Role ^ Owner Controlling- Person - Country/Countries of Tax Residence US Virgin Islands Is Controlling Person a non-US Beneficlary/non-US Beneficial Owner? '/ Yes (complete Appendix 2) No EFTA01478342 First Name ; Last Name Darren Date of Birth 02/19/1965 Country/Countiies of Tax Residence Indyke Controlling Person Typefftoie yp ,Secretary, Director Controlling: Person ' US Is Controlling Person a non-US Beneficiary/non-US Beneficial Owner? 1/' No Yes (complete Appendix 2) First Name Last Name Richard Kahn Controlling Person Type/Role Treasurer, Director Date of Birth Controlling ' Person ! Country/Countiies of Tax Residence US is Controlling Person a non-US Beneficiary/non-US Beneficial Owner? No V Yes (complete Appendix 2) ■.-.it Last Name First Name Date of Birth Controlling Person Type/Rote Controlling Person ; Country/Countries of Tax Residence Is Controlling Person a non-US Beneficiary/non-US Beneficial Owner? ' L No Yes (complete Appendix 2) First Name Last Name Date of Birth Controlling Person Type/Role Controlling;; EFTA01478343 Person Country/Countries of Tax Residence Is Controlling Person a non-US Beneficiary/non-US Beneficial Owner? Each Controlling Person who is also a non-US Beneficlaiy/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. Yes (complete Appendix 2} i - No WM167679 023611.041516 Page Al Entity Self-Certification Form Appendix 2: Non-US Beneficiary/Non-US Beneficial Owner Self-Certification Form Deutsche Bank AG and its affiliates (collectively, "Deutsche Bank") collect certain information, including tax related information, from their clients. Deutsche Bank collects this information to comply with certain 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 is writing to clients and sending you this Self-Certification to complete. As a Non-US Beneficiary/Non-US Beneficial Owner of Account(s) with Deutsche Bank Wealth Management, you are required to state your residency (or residencies) for tax purposes. While Deutsche Bank Wealth Management does not provide tax 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 Self- Certification or about how to determine your tax residency status, please contact your tax adviser or local tax authority. Entity Account Holder; please insert the Legal Name of Entity in #1 of Part 1 below and provide this Appendix 2 to each Non-US Beneficiary/Non-US Beneficial Owner, collect the completed certification and return it to your Deutsche Bank Relationship Manager. Part 1 Non-US Beneficiary/Non-US Beneficial Owner Appendix 2 Is the "Non-US Beneficiary/Non-US Beneficial Owner" Certification. This Appendix must be completed and signed by each non-US Beneficiary and non-US Beneficial Owner of the entity, regardless of whether such EFTA01478344 person is a Controlling Person disclosed in Appendix 1. The attached Guidance to the Entity Self-Certification Form provides assistance for you to determine who the non-US Beneficiaries and non-US Beneficial Owners are. Mort, Inc. Legal Name of Entity to which this Appendix 2 relates Jeffrey Epstein Non-US Beneficiary/Non-US Benefdai Owner Name 01/20/1953 Date of Birth/Dale of incorporation (mm/dd/yyyy) Part 2 Tax Residency Country/Countries of Tax Residence US Virgin Islands If you have additional countries of tax residence, please attach a list of additional countries of tax residence to this form. WM167679 023611.041516 Page A2-1 Declaration and Signature Parts If Non-US Beneficiary/Non-US Beneficial Owner is an individual: 1. I hereby certify that for the purposes of taxation I am not a tax resident in any country other than the country/countries indicated above. 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 going fon/vard will be, taken into account and included in my relevant tax filings if required by the laws of the country (countries) of my tax residence. If Non-US Beneficiary/Non-US Beneficial Owner is 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 country/countries indicated in this 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 Account(s) now EFTA01478345 or in the future held with Deutsche Bank, to any relevant tax or governmental authorities of the country in which the Account(s) is/are/will 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 it receives in the country in which the Account(s) is/are/will be maintained. I understand that this waiver wiil remain in force untii canceiled and notwithstanding canceilation it cannot be terminated retroactively. I declare that all statements made in this Self-Certification are, to the best of my knowledge and beliefj:oFrect^nd complete. I undertake to advise Deutsche Bank w^rcumstancesotwhrcffTam aware of and that causes the information contained herein to bec provide^eu^cberBank w Certification within 30 days of such change in ith a suitably updated Jeffrey Epstein Print Name of Signor Signature 04-28-2016 Date (mm-dd-yyyy) Capacity Note: If signing on behalf of Indicate the capacity in which you are signing (for example Trustee, Corporate/Individual Director, etc.) INTERNAL USE ONLY: Account Number(s): €>2016 Deutsche Bank AG. All rights reserved. WM167679 023611.041516 PageA2-2 promptly of any chapge- ome incorrect ancHo circumstances. ( \ an entity, please EFTA01478346