II. Certification of beneficial owner(s)
Persons opening an account on behalf of a legal entity must provide the following information:
a. Name anti Titleal N-3Z.Lif01 Person Openad Account:
TitCC-rft oe. , ere
b. frame et' Legal Type of Leger Entity. erg! Address ur Legal Entity for Which the Recount is Being Opened:
V. !Fr-:\ c N4.) (St et ...SS, )
Sc; f1C•t if- s•a a.gaia.40-isee..‘ (...)‘%1
le‘
S 4 .CLi.....st, 'AUL oa% o
c. Try: follorring informat:rn for each individual, it any, who. directly CCI 4X6retailt. %hi.111O ?sot crantrnt, mrarrent
understanding. relat;onship or otherwise. ovens 25 oafOOnt or more of the equity interests of the legal entity ilsted above:
Ham.) De; e at Rd?, L.rrJAvi.f.:r3 For!I$ P•Kannt: C:x vari.uS.
3•Ittgih, <t.tett..x.4ra".ni I en: Aetna N•tn
*tit( !<l Social SacgaiityMitrA)il)
For 1....x:4,1 g, Peet.eint tricfrior t; a 5ti,t0, .Set‘etty ,tikettbst .1n 1 Ristira>st. ta.stittw /Alit cl.nireLie of iTwarct thinttficakvn CM* ”trobit. a rm--mtir
and 441.21144y 4.1 .4411,111K4afans•vne tio,t.indient-ISSJed ch)Clitilefg tteltieettl:ln 11.4111111:? 0! ttaitience and 11M11W1c I Oh014434.Vi Of WWII 3.1i4SLAIII 4-64).4111
Nt itain.14011411,011 thtt C•Htetkeet, plefli!nril it riot rearkuJoiel
d. The. Poilowing trtformation for one individual with significant responsibility ror managing the iogai entity find above.
such as:
• An executive offiatr or senior manager (e.g., Chief Executive Ofiket. Officer, Chief Operating Offrrat
Managing Member. General Partner, President. Vice Presdent. Treasurer); or
• An,' otMr individual Who rfil.:tr09?
imly' FM1'101118 futxtions.
(If appropriate. an individual listed tinder section (c) above may ;'150 be tinted in this section (d)).
pact•V:Iiittt 110*Atiesstek)
• Fe/ U.S. PL•sswa ;tor I.4.7r14.11). Peqcr
PA;6:445ec;;et," i.l.efotqr.);t fr.-- {tem:pr.:et -
to Social Sta.:;ait". MUM 00
Fe.A Piwrxm. ta a $t-z- . 'ten i•Mmtik.riC-Tt Calf MIMI'S Cr nt.ertbor
andC.401re CrItiDtarieit NW Cflen ift)e., t• ti ploteiy.g)h CO POWS 4.0./W., touts
.ttS paage.1-0
I, A Cgretf . cfork tr.% (name of natwai person opening the account), hereby certify. to the best of
n y knowledge. tNat t e int • rn ;_s tunplate and correct.
Ltgai in:ay 4tot;fer (eviong.)
‘1201t, ileutiche Bat-.: ntl room. teSafroa, 1.,trvIleeMio 120.1i).(731418
CONFIDENTIAL - PURSUANT TO FED. R. CRIM. P. 6(e) DB-SDNY-0079830
CONFIDENTIAL SDNY_GM_00226014
EFTA01381083