Entity Self-Certification Form
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 details of each Controlling Person below. Please continue on a separate sheet it necessary (and attach to
this form).
ConlnNl;ng
Person
Cannoning;
Pere
Penton
Conlr.).5 I
Pprion
Control i no
Person Fest Mn Jeffrey Last Name Epstein
Dal° of Beth 01/20/1953 C°^"Img Pcrual TYPef"° Pres., Dir., Ben. Owner
Count:Swedes of Tax Residence
US Virgin Islands
is Controlling Person a non-US
Bonentratyrnon.US sellers al Owner?
Fall Da" Darren
DP10 of Birth
Countiy/Countnes el Tax Residence
US
Is Controling Person a non-US
geneficktryWorrUS Denefteel Owner?
Fast Da" COC1Ift ✓ Yes (complete 4/M00ot 2) NO
last Name lndyke
Controlling Person TTPagalala Treas., Secy., Director
Yes (complete Appendix 2)
Lad Na" de Jongh i/ No
Date of Controlling Person TY04111aale Director
Coontn/(Countries of Tax Residence
US Virgin Islands
Is Controlling Persona non-US
BeneSsiary/non-US Elowectal Owner?
est Name
Dale of /Inn
Country/Gamut ol Tax Residence
Is Controlling Persona non-US
Beneficiary/non.U$ Beneficial Clymer?
Pest Heine
Date of Birth
CcontrytCountnes of TeX Residence Yes (complete Appende 2) ✓ No
Last NAOMI!
Comrolling Person Type:Rote
Yes (complete Appendix 21 No
Lost Name
Controlling Person Typeillolo
Is Controlling Person a non-US Yes (corneae. Appendix 2) No BeneficiarythonrJS BeneRcial Owner?
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.
WMI61679 023611 041516
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CONFIDENTIAL - PURSUANT TO FED. R. CRIM. P. 6(e)
CONFIDENTIAL DB-SDNY-0062088
SDNY_GM_00208272
EFTA01369667