EFTA Document EFTA01369678

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 it necessary (and attach to this form). First NangiJOffraY 14 9 Dale of Br) 01120/1953 Counlrynounines of Tax Residence iNy US Virgin Islands le Controsing Person a non-US Benallastehon-US Beneficial Omer? Yes (complete Appendix 2) 4/ No 44 Fat Name Darren Dale oil BIM v i enees CourswiCouninut ot In Passim US Is Confiding Person a non.US Benegoaryhson-US Beneficial Omer? PmNameRichard Dale °Seth 12/06/1972 cassava:Rimers at Tax Residence US Is Controlling Person* non-US Bteenclecifnen-US Bet Owner? Fast Name Mark an cif Bill 7/14/1954 Cotetyltountaes of Tax Residence US ts Conde/Re Parson a non.US Berierciarylnon-US Beneficial Owner? Last Name Epstein Convening Person TypeiRole Trustor tat Indyke CortIroang Person Typsaiolo Trustee Yes (comply* Appendix 2) I No Lae& Name Kahn Controlling Person Typeflole /hates Yes {conelea Apperata 2) Last Name Epstein controlling Person TwieRole Beneficiary No Yes (complete Append* 2) Fes Name ca ne La g NW/. Dubin DateatBirth3/31/1995 CouttyCountries of Tax Residence US Is Convolimg Persona non-US Beneficiary/non-US Benefice' Omer? 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 wtth a tax residence solely in the United States is not required to complete and sign Appendix 2. No Controlling Poem PIPWRole Beneficiary Yea (compete Appendix 2) .0' No WM161679 023111.041516 Page At CONFIDENTIAL - PURSUANT TO FED. R. CRIM. P. 6(e) DB-SDNY-0062103 SDNY_GM_00208287 CONFIDENTIAL EFTA01369678