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sd-10-EFTA01356689Dept. of Justice

EFTA Document EFTA01356689

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KYC Print Page 12 of 43 One sheet must be established for EACH INDIVIDUAL PARTY in Section 2. Account Ownership Summa 3A. Individual Details (for all part es) Individual's Name: Harry Beller - 00000487202 Date of Birth: Country of Residence: United States Country of Citizenship: United States Address of primary residence: Monsey NY 10952 United States Has client resided outside of his/her country of nationality for 5 years or more? Li Yes g No Profession/Occupation: Accountant

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Dept. of Justice
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sd-10-EFTA01356689
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