EFTA Document EFTA01357585

Entity's Financial Details Annual Income: D Less than $50,000 60.000-99.999 CI 100.000-249.999 O 250,000-499,999 500,000-999,999 O 1,000.000.2.499,999 O 2,500,000-4,999,999 CI 5.000,000 and over Net Worth: O Less than $50.000 K 50.000-99,999 O 100,000249.999 0 250,000-499.999 K 500,000-999.999 CI 1,000,000.2.499,999 0 2,500,000-4.999,999 0 5.000,000 and over Entity's Source of Wealth (Check all that apply) O Inheritance or Gifts O Corporate Executive O Sale of Other Assets