EFTA Document EFTA01369669

?an I) i:tclarat'93; $44'1.ature - If Non-US Beneficiary/Non-US Beneficial Owner Is an Individual: 1. I hereby certify that for the purposes of taxation I am not a tax resident In any country other than the country/countries Indicated above. 2. I confirm that my ownership or other interest In the Entity, if any. is appropriately disclosed in accordance with applicable laws and regulations in the countries In which I am tax resident and may be required to be reflected in my tax filings. 3. I confirm that all income or capital distributions received (or deemed to be received for tax purposes) by me from the Account(s) have been, and going forward will be, taken into account and Included in my relevant tax filings If required by the laws of the country (countries) of my tax residence. If Non-US Beneficiary/Non-US Beneficial Owner is an entity: 1. I hereby certify that for the purposes of taxation the non-US Beneficiary/non-US Beneficial Owner Is not a tax resident in any country other than the country/counMes indicated In this self-certlfication. 2. I confirm that my ownership or other interest in the Entity. if any, is appropriately disclosed in accordance with applicable laws and regulations in the countries in which I am tax resident and may be required to be reflected in my tax filings. 3. I confirm that all income or capital distributions received (or deemed to be received for tax purposes) by me from the Account(s) have been, and will be, taken into account and included in the relevant tax filings if required by the laws of the country (countries) of tax residence. I agree that Deutsche Bank may disclose this Certification and any other information related to it or the Account(s) now or in the future held with Deutsche Bank. to any relevant tax or governmental authorities of the country in which the Account(s) islare/will be maintained or of any country in which I may be liable to pay taxes. I release Deutsche Bank from any obligations of bank secrecy, confidentiality and/or data protection under any applicable laws which might otherwise preclude the disclosure of such information. I acknowledge that the data protection laws of such other countries may not afford the Information the same protections which it receives in the country in which the Account(s) Is/are/will be maintained. I understand that this waiver will remain in force until cancelled and notwithstanding cancellation it cannot be terminated retroactively. I declare that an statements made in this Self-Certification are, to the best of my knowledge and belief, cope-and complete. I undertake to advise Deutsche Bank promptly of any change in of which I 'aware of and that causes the information contained herein to become incorrect and to p ode Deutsche k wi _suitably. UPdated Certification within 30 days of such change in circumstances. Jeffrey Epstein Print Nam* c4 Signor 04-28-2016 Dale (IT ne0-100/2) Capaaty Note: If scars on Iscesstl of an entity. please indicale the capacity in when you are signing (for example Trustee. Caporetnindanuts Director. etc.) Signature INTERNAL USE ONLY: Account Numbor(s). O 2016 Deutsche Bank AO. Alt rights reserved. V031167679 023611 041516 Page 424 CONFIDENTIAL - PURSUANT TO FED. R. CRIM. P. 6(e) CONFIDENTIAL DB-SDNY-0062090 SDNY GM_00208274 EFTA01369669