EFTA Document EFTA01369667

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 it necessary (and attach to this form). ConlnNl;ng Person Cannoning; Pere Penton Conlr.).5 I Pprion Control i no Person Fest Mn Jeffrey Last Name Epstein Dal° of Beth 01/20/1953 C°^" Img Pcrual TYPef" ° Pres., Dir., Ben. Owner Count:Swedes of Tax Residence US Virgin Islands is Controlling Person a non-US Bonentratyrnon.US sellers al Owner? Fall Da" Darren DP10 of Birth Countiy/Countnes el Tax Residence US Is Controling Person a non-US geneficktryWorrUS Denefteel Owner? Fast Da" COC1Ift  Yes (complete 4/M00ot 2) NO last Name lndyke Controlling Person TTPagalala Treas., Secy., Director Yes (complete Appendix 2) Lad Na" de Jongh i/ No Date of Controlling Person TY04111aale Director Coontn/(Countries of Tax Residence US Virgin Islands Is Controlling Persona non-US BeneSsiary/non-US Elowectal Owner? est Name Dale of /Inn Country/Gamut ol Tax Residence Is Controlling Persona non-US Beneficiary/non.U$ Beneficial Clymer? Pest Heine Date of Birth CcontrytCountnes of TeX Residence Yes (complete Appende 2)  No Last NAOMI! Comrolling Person Type:Rote Yes (complete Appendix 21 No Lost Name Controlling Person Typeillolo Is Controlling Person a non-US Yes (corneae. Appendix 2) No BeneficiarythonrJS BeneRcial 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. WMI61679 023611 041516 Page Al CONFIDENTIAL - PURSUANT TO FED. R. CRIM. P. 6(e) CONFIDENTIAL DB-SDNY-0062088 SDNY_GM_00208272 EFTA01369667