EFTA Document EFTA01460274

Entity Self-Certification Form Appendix 1: Controlling Persons Appendix :I 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). Controlling Proton Can Ironing Pend etathtlINI Pnrou CatitroVINty Par son . Curio/ulna, Perhan Rat NOTO Jeffrey Last Name Epstein Dale a Bernet/2011953 ConVolling Person Type/Role Trustor Country/Cot/nines of Tax Residence US Virgin Islands Is Controlling Persona non-US Benericoryinon-US Beneficial Ownet? Fist "3`" Darren Dale 1)4 COUntry/Countras of Tax Residence US Is COnlieling Person a non-US Banaidatyloco-US Benefioal Owner? F" Ha" Richard CourOy/Counetes at Tax Residence US It Controlling Persona non-US Beneficiory/non-US Sanaa*/ Owner? Yea (compote Append: 2)  NO cost Nal" Indyke Controlling Person Tyl:arRole Trustee Yet (compels Appendix 2)  No Yes (complete Appenax LAM Na" Kahn Conlrolag Person Type/Role Trustee  No First Nam° Mark Last Na" Epstein Date of Etlimin. Control/no Parson Tyco/Re/0 Beneficiary Country/Countries of Tax Residence US Contains Person a non-US Banalliciaryinco-US Beneficial Owner? First Nainfacelina Dale of Birth CounDylCountsies of Tax Residence US Yes (compote Appendix 1 No Lal' Name Dubin Controlling Parson Tif>05(0M Beneficiary la Common Person a non-us Yes (carnal° Appendix 2)  No Beneficiary/non-US Beneficial Owner? Each Controlling Person who Is also a non-US Beneficlary/non-US Beneficial Owner must complete and sign Appendix 2: Beneficiary/Beneficial Owner SelfiCertification Fonn. 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. WM167679 023611.041516 Page Al CONFIDENTIAL - PURSUANT TO FED. R. CRIM. P. 6(e) DB-SDNY-0 121392 CONFIDENTIAL SDNY_GM_00267576 EFTA01460274