EFTA01478358Set 10
11p2,089w
attach a list of
additional countries of tax residence to this form.
WM167679 023611.041516
Page A2-1
Declaration and Signature
Parts
if Non-US Beneficiary/Non-US Beneficial Owner is an individual ... example Trustee, Corporale/lndividual Director, etc.)
Account Number(s}:
INTERNAL USE ONLY:
020160eutscheBankAG.AIIrightsreserved. WM167679 023611.041516
Page A2-2
EFTA01478368
https://www.justice.gov/epstein/files/DataSet%2010/EFTA01478358.pdf