EFTA Document EFTA01370174

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 if necessary (and attach to this tom). conceding Person Control:log Plosan First Nan* Jeffrey In Nam° Epstein Dale 'If sun 1/20/1953 Controlling Person TypetRae Pres., Dir., Bon. Owner Counny/Countnes of Tax Residence US Virgin Islands Is Controlling Parson a non.US BenefolarytnowUS Beneacial Owner? First Nam° Darren Oats ad Bah CouneyfCcontries of Tax Residence US is Controlling Person anon-US BeneficiarylnorfrUS Beneficial Owner? Yes (complete Addenda 2) No Last Name Indyke Conlading Person TYPornallVP ,Secretary, Director Yes (coincide Appendix 2) No CoolM arm Parson Rst bilm. Richard Oat aenl 12/8/1972 Couney/Cournries of Tax Residence US Lail N"* Kahn Controlling Person Type/Rae Treasurer, Director Is Conflating POTSCO a non-VS Beneficiaryinon-uS Brrnerr-ix Ownw? Yea (canon ApPOOCItC 2) No Firs! Name Last Name Dale of Birth CoNrcAng Person Typeffiole Cur:belting CauntyrOdunbles of Tax Residence Parson • Is Ceeciang Person a non US Benelkiaryrrion-US Beneficial Owner? Yes (complete Appendix 2) No Fast Name Last Name Cate of Binh Controlling Person TypaRole Contro!iincy Country/Ca/nines of Tax Residence Parton Is Controwng Person a non-US Bene5vistyfrain-US Beneficial Oraws7 Yes (complete Appends( 2) No 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. W51167679 023611O41516 Page Al CONFIDENTIAL - PURSUANT TO FED. R. CRIM. P. 6(e) DB-SDNY-0062812 CONFIDENTIAL SDNY_GM_00208996 EFTA01370174