EFTA01377442.pdf

Individual Self-Certification Form Part 1 - Individual Account Holder Information 1. Account Holder Name: Jeffrey Epstein 2. Date of Binh (mtrilddiyyyy): Part 2 — Tax Residency and Tax Compliance Status For the purposes of taxation, I am a tax resident of the following country/countries: Country of Tax Residence: US Virgin Islands If the Account Holder has additional countries of tax residence, please attach a statement to Ibis form containing the required information outlined above. 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. 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 in the countries in which I am a tax resident and may be required to be reflected in my tax filings. I confirm that all assets held with Deutsche Bank Wealth Management, as well as any and all income related thereto, where applicable, have been, and going forward will be, taken into account and included in my relevant tax filings when determining my tax obligations. Part 3 — Declaration and Signature I understand that the information supplied by me In this Certification (including any attachment hereto) is provided pursuant to the full terms and conditions governing the Account(s) and my 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 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/areAvill be maintained or of any country in which I may be liable to pay taxes. I release Deutsche Bank from any obligations of bank secrecy, confidentiality and I or data protection under any applicable laws which might otherwise preclude the disclosure of such information. I acknowledge that the data protection fawn 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 all statements made in this Self•Certification are, to the edge arliefroom!kririd complete. I undertake to advise Deutsche Bank promptly of any causes the information contained herein to become incorrect and to provide Deutsche ted Self.Certification within 30 days of such change in circumstances. ...49.fifitY..?Weill Peed Name 4-28-2016 ONe (rmi-cIllyry) D capacity Check this box if you are signing as a legal guardian for a minor or on behalf of an individual who lacks to sign. Internal Use Only Account Nurnbegay VAIRITICK)023KGAD1516 Pe 2 art CONFIDENTIAL - PURSUANT TO FED. R. CRIM. P. 6(e) DB-SDNY-0074279 CONFIDENTIAL SONY GM_00220403 EFTA01377442