EFTA01298376.pdf

II. Certification of beneficial owner(s)
Persons opening an account on behalf of a legal entity must provide the following information:
a. Name and Title of Natural Person Opening Account
ea. A
and Sec fe4r.
b. Name of Legal Entity, Type of Legal Entity, and Address of Legal Entity for Which the Accountleing Opened:
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e.
The following information for each individual, if any, who, directly or indirectly, through any contract, arrangement
understanding, relationship or otherwise, owns 25 percent or more of the equity interests of the legal entity listed above:
Name Dated BIM Lagar Address For U.S. Parsons: i rot Non.U.S Wenn:
Social Saville j (Sec foornow 1 for alternatives
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' For Non.U.S. Persons. accit;on toe Social Security Number cif a renpon Number with Country of Issuance. an alien identification card number.. or number
and country of 'nuance of any othor government-isSued dxumeot ericeneing natiVitlOty V casidence one txarew a onotocrepn ce similar safeguam snoula
be orovioto.
flf no iritivicwat lneolt this deli:NOVI. POMO write "Not AoplIcable.1
d. The following information for one individual with significant responsibility for managing the legal entity listed above,
such as:
• An executive officer or senior manager (e.g.. Chief Executive Officer, Chief Financial Officer, Chief Operating Officer,
Managing Member, General Partner, President, Vice President Treasurer); or
• Any other individual who regularly performs similar functions.
(If appropriate, an individual listed under section (c) above may also be listed in this section (c)).
'Nana i Date of Heil I Legal Address I For U.S. Perst‘n Fty Non.U.S. Pelona:
Social Security (See footnote I. for alternatival
Number to Social Secures Nuance)
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For Non-U.S. Persons. in addition 10 a Social Security Number or a Passport Number' ..vith Country of Issuance. an alien ieedification add number. or humps,
and codntey cg issuance of any °e'er 90ventrafit-inuta OcCunivit eviclohcito nximmids or rcskianoc and boating a photograph Cr similar safeguard ShOult1
be prOviO*0.
I, '‘h.e saCrn- AL att./4 (name of natural person opening the account), hereby certify. to the best of
complete
my knowledge, that the information provided above is and correct.
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If Name (Print):
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CONFIDENTIAL — PURSUANT TO FED- R.CDN(E DB-SDNY-0025549
EFTA_00173232
EFTA01298376