EFTA Document EFTA01345324

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 continue on a separate sheet if necessary (and attach to this form). first Na.tIM Data el Brat CounifloCoundes of Tax Residence US Is Contrelling Person a non-US flenefetaryfron-US Beneficial Owner? First Warne J e ffrey Dale of Birth CalterYfOounten of lax R4140€04, US Virgin Islands Is Contoiling Person a non.US BeneficiarylnoniUS Beneficial Owner' Pest Name- Dale of Birt Country(Countrais of Tax Residence US Virgin Islands Is Condoning Person a non-US BenefiestyrnoreUS Benefifial Owner? First Nem Oahe of Birth Country/Countries of Tax Residence US Is Ccedroling Person anon-US Berinearynon-US Beneficial OWIllf, feu Name Date ot Owls Couneatounisies of Tax Residence is Ccnirolling Person a non. US Beneficiary/non-US Beioneal Owners 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. Last Name_ COnffeartfi Pcioe TT"'Ree President Yes (comcsoteAimende 2i I No La" Nora Epstein Cm/I.:ding Ps3" TTPRIfin'" Director Yet (complete Appendix 2) J No last Nemo COrdrOlfing "OM^ fyriemelfl Secretary, Director Yes (=wine Appends 21 I to Last Name Causing Munn TrDotl°41Treasurer, Director vas (complete appendix 2) No LOM Name Canoeing Pyson Ittaefffifie Yes fcctmotetc naPendix 21 NO wm167679 023G f 154 Pepe Al CONFIDENTIAL - PURSUANT TO FED. R. GRIM. P. 6(e) DB-SDNY-0031598 CONFIDENTIAL SDNY_GM_00177782 EFTA01345324