EFTA Document EFTA01362422

KYC Print Page 17 of 34 One sheet must be established for EACH INDIVIDUAL PARTY in Section 2. Account Ownership Summa 3A. Individual Details (for all parties) Individual's Name: Harry Beller - 00000487202 Date of Birth: 5/9/1956 Country of Residence: USA Country of Citizenship: USA Address of primary residence: 12 Golar Drive Monsey 10952 United States Has client resided outside of his/her O country of nationality for 5 years or more? Yes rk No Profession/Occupation: Account