EFTA00608096.pdf

HSBC Private Bank Attn: General Counsel/LEGIT 9-17 Quai des Bergues PO Box 2888 1211 Geneva 1 Switzerland CONFIRMATION Closed accounts and (your "Accounts") at HSBC Private Bank (Suisse) SA (the "Bank") Confirmation of declaration to the US Internal Revenue Service (the "IRS") or Confirmation of participation in an Offshore Voluntary Disclosure Program/Initiative (the "VD Program") Release of Swiss bank secrecy (and related obligations) Dear Sirs, ❑ I hereby confirm that my Accounts have been declared to the US Internal Revenue Service. This is evidenced by: ❑ the Report of Foreign Bank and Financial Accounts (FBAR), a copy of which is enclosed to this reply letter. ❑ other documents, such as a copy of an IRS tax return filing or a certification from a US qualified tax advisor or US lawyer stating that my Accounts have been declared to the US Internal Revenue Service, which is/are enclosed to this reply letter. ❑ other form(s) (e.g., Forms 8938, or 8832, or 5471, or 8621, or 3520, or 3520A), as applicable. and/or ❑ I hereby confirm that my Accounts have been disclosed to the IRS through a VD Program or Initiative following notification by the Bank of such program or initiative. The participation in a VD Program or Initiative is evidenced by the documentation enclosed to this reply letter. Or ❑ I would like to receive assistance from the Bank (in particular the recommendation of outside counsel) in order to be in a position to take part in the VD Program. Furthermore, I expressly authorize the Bank to disclose my name as well as any other information related to the Account, to the US authorities, in particular to the US DOJ and US IRS. For this purpose, I hereby expressly release the Bank, its affiliates, directors, partners, officers, employees, representatives and agents from any obligations of bank secrecy, confidentiality and(or data protection under Swiss or any other applicable law(s) which might otherwise preclude the disclosure of such information. Yours faithfully, Name: Signature: Date: Page 1 of 1 EFTA00608096