EFTA Document EFTA01362359

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 Conholing Person below. P10850 Continue on a separate sheet if necessary (and attach to this form). resligameRich Daroac ant 12/06/1972 CounagfCmanales of Tex Residence US Is Gangrening Person a non-US Beneficiary/non-US Beneficial Owner First Name J e ffrey Dale of Birth 01120/1953 CountryiCountiiin of Tax Residence US Virgin Islands Is Conte:fling Person a noniUS UeneficiarylnoniUS Beneficial Owners • Last Name Kahn COMMIM Person TY9ORCI. President Yes (corncroteaatiendie 2i J No "" No"Epstein Cm/I.:ding Pwrim' TSPRIRat" Director Yet (comowe Appendix 2) J No Fat Mama Erika Lag Neste Kenerhais °al° °Bath 10/13/1974 CounfroCourino5 of Tax Rosana US Virgin Islands Is Controaing Person a non-US BenermasytnoreUS Beneficial Griner? Pint Was" Darren Data at8°h 02/19/1965 ; Countretountries ce Tax Reto64.-tee US Is Cmgroling Person non-US BenoficeiryinoniUS Seneficial Owner, rest Name Date oi Owle Countrytounisies of Tax Retilena• Controlling nano^ riirmattsta Secretary, Director Yes (=wrote armee* 21 No Last ""Indyke caucan9"" n TTaCats Treasurer, Director Yes (romplete fit:pendia 2) Mo LON Name Coretolling Pinson Tyserficre la Coeirolling Person a noniUS Yes (Carpiete Aapenew NO asiwriciaryMen-US Sene5oal Owner, 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. wM167629 02% I f Oa 1 SIG Pegs Al CONFIDENTIAL - PURSUANT TO FED. R. GRIM. P. 6(e) DB-SDNY-0051742 SDNY_GM_00197926 CONFIDENTIAL EFTA01362359