EFTA Document EFTA01460269

?an I) i:tclarat'93; $44'1.ature - 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 am tax resident and may be required to be reflected in my tax filings.