EFTA Document EFTA01370185

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 detaas of each Controfling Person below. Please continue on a separate sheet it necessary (and attach to this form). COT gf0:1111a P0:14LI Canto!! irx)}. Parton Contrctrinsi denier, Cry:trolling Parson Ant Name Jeffrey Oats of Birth 01/20/1953 Country/Countries of Tax Resdenee US Virgin Islands is Controlling Person a non-US Benerroary/non.US Beneficial Owns!! Lati Name Epstein Controlling Person TypidRcle Trustor/Trustee/Beneficiary .1 Yes (compkrie Appends No Fiat NomeDarren " St NW" Indyke Dated Beth 02/19/1965 Controlling Person Type/Role Trustee Courey/Countros of Tax Resident* US Is Controlling Person a non-US Benelidary/non-US Beneficial Avner? First Name Oats of Beth 1:pentode-domain of Tax Residence Is Command Person a non-US Beneficianynon.US Beneficial Owner? Alt NINON Dote of Bit. Country/CdunInedi of Tax Residence Controlling Person a non-US Benef.ciery/non.US Beneficial Owner? First Name Date or Bab Country/Countries of Tax Residence Yes (eeent ° APPender 2) Las! Name Controlling Person Type/Role I No Yes (complete Appencitx 2) No Lag Name Controlling Person TypeiRole Yes (complete Appendix 2) Last Name Controlling Person Type/Role No Is Controlling Person a non.US Yes (complete Appendix 2) No BenelidarytnendlS Beneficial Oyster 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. WM167679 023611 041516 Page Al CONFIDENTIAL - PURSUANT TO FED. R. CRIM. P. 6(e) DB-SDNY-0062831 CONFIDENTIAL SDNY_GM_00209015 EFTA01370185