EFTA Document EFTA01460224

Pert 3 If Non-US Beneficiary/Non-US Beneficial Owner is an Individual: 1. I hereby certify that for the purposes of taxation I am not a tax resident in any country other than the country/countries indicated above. 2. I confirm that my ownership or other interest in the Entity, if any, is appropriately disclosed in accordance with applicable laws and regulations in the countries In which I em tax resident and may be required to be reflected in my tax filings. 3. I confirm that all Income o