EFTA Document EFTA01357588

Beneficial Owner's Information Please complete if owner is NOT an authorized person. Name: OR Entity Name: DOB or Date of Establishment: SSN or TIN: Legal Address: City: State: Zip/Postal Code: Country: Country of Citizenship: If not U.S. (check one): O Resident Alien O Non-Resident Alien Employment Status: O Employed O Self-Employed O Retired O Unemployed O Homemaker O Student Occupation and Position: Employer's Name: Employer's Address: City: Length of Employmen