EFTA Document EFTA01377442

Individual Self-Certification Form Part 1 - Individual Account Holder Information 1. Account Holder Name: Jeffrey Epstein 2. Date of Binh (mtrilddiyyyy): Part 2 - Tax Residency and Tax Compliance Status For the purposes of taxation, I am a tax resident of the following country/countries: Country of Tax Residence: US Virgin Islands If the Account Holder has additional countries of tax residence, please attach a statement to Ibis form containing the required information outlined above.