EFTA Document EFTA01460122

Dart Declaration and Signature I understand that the information supplied by me in this Self-Certification (including any attachment hereto) is provided pursuant to the full terms and conditions governing the Account and the Account Holders contractual relationship with Deutsche Bank setting out how Deutsche Bank may use and share the information supplied by me to Deutsche Bank. I agree that Deutsche Bank may disclose this Self-Certification and any other information related to it or the Account(s) now or in the future held with Deutsche Bank, to any relevant tax or governmental authorities of the country in which the Account(s) is/are/will be maintained or of any country in which the Account Holder may be liable to pay taxes. I release Deutsche Bank from any obligations of bank secrecy, confidentiality and/or data protection under any applicable laws which might otherwise preclude the disclosure of such information. I acknowledge that the data protection laws of such other countries may not afford the information the same protections which it receives in the country in which the Account(s) is/are/will be maintained. I understand that this waiver will remain in force until cancelled and notwithstanding cancellation it cannot be terminated retroactively. I declare that the below statements are, to the best of my knowledge and belief, correct and complete: 1. I hereby certify that for the purposes of taxation the Account Holder is not a tax resident in any country other than the country/countries indicated in this Self-Certification. 2. I am aware that income deriving from the Account(s), as well as related transactions, may trigger a tax liability in accordance with applicable laws and regulations and that this may be reflected in the Account Holder's tax reporting. 3. I confirm that all assets held by the entity with Deutsche Bank Wealth Management, as well as any and all income and gains related thereto, where applicable, have been, and will be, taken into account and included in the relevant tax filings as required by the laws of the country(countries) of tax residence. I declare that all statements made and information contained in this Self-Certification (including the information in Appendix 1 and Appendix 2, as applicable) are, to the best of my knowledge and belief, correct and complete. I undertake to advise Deutsche Bank promptly of any change in circumstances of which I am aware of and that causes the information contained herein to become incorrect and to provide Deutsche Bank with a suitably updated Self-Certification within 30 days of such change. I further certify that I am duly authorized to sign for this Account Holder and to provide all the confirmations herein with respect to all the Account(s) to which this Self-Certification relates. Print Name Date (rnm-dd-yyyy) Capacity Note: Please indicate the capacity in which you are signing the form (for example Trustee. Corporate/Indialual Diector. etc.) Vtert167619 023611.041516 Paget of 5 Signature CONFIDENTIAL - PURSUANT TO FED. R. CRIM. P. 6(e) CONFIDENTIAL DB-SDNY-0 121083 SDNY_GM_00267267 EFTA01460122