EFTA Document EFTA01460267

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 form). Corkin-4n'. Potion Cone °gruel Pereal. Contrislifitt Prlinen COnto5 I Parton Control!' ng ren.00 Firm Nem* Jeffrey Las/ Name Epstein Dal° °Ball 01/20/1953 C°^" Img Pecs" TYPef" ° Pres., Dir., Ben. Owner CountryCouMnes of Tax Residence US Virgin Islands Is Controlling Potson a non-US annofimaiyMon.US Banancial Ownee? First Nam. Darren  Yes (comp** Appendix 2) No Last Name inctyke Date of Bit•..,•. Controlling Person TYPTIR°. Treas., Secy., Director County/Coon/nets oh Tex Resedenoa US Is Connoting Person a non-US SeneficktrynotrUS Denefic'el Owner? FmTi Nam. Cecile pa CalititiCounties of Tax Res.donce US Virgin Islands Is Controlling Person a non-US BeneAotaryfnenA/S13eneffusal Oa? tag Name Dale of Ruth Country/Camtries of Tax Residence le Cootroang Persona non-US eenefidary/ran-U$ eeneectei Ovals& Pest Name Date of SIM Ccuntry/Countnes of TeX Residence Yes (complete Appendix 2) No Lad Nast. de Jongh Controlling Person TYPeinc4a Director Yes (complete Appends 2)  No Last Neale CoMrolling Person Type:Rae Yes (ccelaiete Appendix he Lost Name Coraraiing Person TyoefRolo Is Controlling Poison a non-US Yes /compleici Appends 2) No BeneaciaryMoAUS Beide:el 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. WM161679 023611 041516 Page At CONFIDENTIAL - PURSUANT TO FED. R. CRIM. P. 6(e) DB-SDNY-0121379 CONFIDENTIAL SONY GM_00267563 EFTA01460267