EFTA Document EFTA01460156

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). First Name Dale ol ELM) Last Name Controlling Person Type/Role CatoDeo) Country/Countries ol Tax Rem!once Person Is Conti°Ong Poison a non-US Bone? try/non-US Beneficial 0Ane0 Yes (compels Appenda 2) No First Name Last Name Date of Birth Connoting Person Typo/Role Controlling Country/Countries of Tax Residence Person Is Controllrg Person a non-US Beneficiary/non-US Beneficial Owner? Yes (compkde Appendix 2) No First Name Last Name Date of Binh Connoting Person Type/Role Controlling Country/Countries of Tax Residence Pelson Is Controlling Person a non•US Beneficiary/non-US Beneficial Onner? Yes (compele Appendix 2) No First Name Last Name Date of Uth Controlhng Person Type:Role COntr011efg Country/Countries of Tax Residence Pecson Is Controlling Pelson a non-US Beneficiary/non-US Beneficial Omer? Yes (oompele Appenda 2) No First Name Last Name Date of Birth Contioling Person Type/Role Contain° Country/Countries of Tax Residence Person Is Controlling Person a non-US Beneficiary/non-US Beneficial Omer? Yos (complete APFonda No 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. Yleel 167679 023611.041516 Page Al CONFIDENTIAL — PURSUANT TO FED. R. CRIM. P. 6(e) DB-SDNY-0 121178 CONFIDENTIAL SDNY_GM_00267362 EFTA01460156