EFTA Document EFTA01369090

DECLARATION OF STATUS FOR ISRAELI INCOME TAX PURPOSES (This declaration should be completed only by Non-Israeli Residents and Israeli Brokers.) You are retching this form "Declaration of Status for Israeli Income Tax Purposes" as a holder of Ordinary Shares, nominal value €0.01 per share, per share (the "Shares") of Mobileye N.V. (the "Company"), in connection with the tender offer. By completing this form in a manner that would substantiate your eligibility for an exemption from Israeli withholding tax, you will allow paying agent, Israeli withholding tax agent, your broker or any other withholding agent, or their authorized representatives to exempt you from Israeli withholding tax. PART I , Identification and details of Shareholder (including Eligible Israeli Broken) (see instructions) 1. Name: 2. Type of Shareholder (more than one box may be applicable): (please print full name) Sc LI Ikc re. n n of. L.t GI L Lc Q.Pe Corporation (or Limited Liability Company) 0 Individual 0 Trust 0 Partnership 0 Other: O Bank O Broker O Financial Institution 3. For individuals only: 4. For all other Shareholders Date of birth: / / Country of incorporation or organization: 11 S. V .'rrtin \s‘O.ni13 month/ day / year Country of residence: Registration number of corporation (if applicable): Car p. No. St3Wci Countries of citizenship (name all citizenships): Taxpayer Identification or Social Security No. (if applicable): Country of residence: Li . S. Iii. ; rki 4n. IS 1O eal 5. Permanent Address (state, city, zip or postal code, street, house number, apartment number): (n1OO V, c d tiook a ctori-cr IV'S . g k .Thorfas USVI OO7(Y.2 6. Mailing Address (if different from above): 7. Contact Details: Name: ki, kor el Kok; num er : Capacity: - Telephone Number (country code, area co e an 8.1 hold the Shares of the Company (mark X in the appropriate O directly, as a Registered Holder raihrough a Broker. If you marked this box, please state the name place): of your Broker bc,LV5C k a Ric.r.1- 9. 1 hold less than 5% of the Company's issued shares. Yes fi No O CONFIDENTIAL - PURSUANT TO FED. R. CRIM. P. 6(e) CONFIDENTIAL DB-SDNY-0061176 SDNY_GM_00207360 EFTA01369090