EFTA Document EFTA01478405

Individual Self-Certification Form Part 1 - Individual Account Holder Information Jeffrey Epstein 1. Account Holder Name: 2. Date of Birth (mm/dd/yyyy): 1/20/1953 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 this f orm containing the required information outlin