EFTA01298644.pdf

Deutsche Bank
Wealth Management
Entity Self-Certification Form
Purpose of this Self-Certification Form
Deutsche Bank AG and its affiliates (collectively. 'Deutsche Bank') collect certain information, Including tax relateo
information, from their clients. Deutsche Bank collects this information to comply with ce.•tain local and international
regulatory requirements that are designed, among other things, to foster and support a tax compliant environment.
Although these requirements are not necessarily imposed by all countries. Deutsche Bank. as a global bank that strives
to achieve consistency in its practices among all of Its regions. nonetheless requires this information be provided by clients
even if not required by regulation. Accordingly. Deutsche Bank Wealth Management Americas rs writing to clients and
sending you this Self•Certifiation to complete.
This form is to be used in any situation where the Account Holder is an erieV. and not an individual, If in fact the Account
Holder is an individual, the Individual should complete and provide the Individual Self-CerfificatIon Form which you can
obtain by contacting your Deutsche Bank Wealth Management Americas Relationship Manager.
Please note that a branch of an entity is treated as the entity for purposes of this Self•Certifiation and, therefore. the form
Should be completed with details for the branch, and not the details of its parent.
Please complete all sections below as directed and provide any additional information as may be required. For the
purposes of this Self•Certifiation. -Account(s)- includes any accounts currently held with Deutsche Bank by the entity.
White Deutsche Bank Wealth Management does not provide lax advice. you may contact your Relationship Manager if
you have questions concerning the Self-Certification process. If you have any questions about how to complete this form
or about how to determine your tax residency status, please refer to the attached Guidance to the Entity Self•Certifation
Form, or contact your tax adviser cr local tax authority.
The Haze Trust
L4.931 Name 04' EAMy
US
Cooney or Ircofpcfacon of Ofearetaboo
Entity's Country (Countries) of Tax Residence
US Vigin Islands
If Entity Account Holder is tax resident only in the United States, please proceed directly to Appendix 2 (which
must be completed by each non•US Beneficiary and each non•US Beneficial Owner). If Entity Account Holder is
tax resident outside the United States, please proceed to Part 2 and complete Appendix al and Appendix 2.
Please insert the Legal Name of the Entity in Part l of Appendix 2.
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Entity Self-Certification Form
Appendix 1: Controlling Persons
Appendix 1 must be completed for each Controlling Person of the entity, but only if the entity has a tax residence
outside the United States. Please refer to the attached Guidance to the Entity Self-Certification Form which
provides assistance for you to determine the Controlling Persons and how to complete this Appendix.
Please provide details of each Controlling Person below. Please condole on a separate sheet If necessary (and attach to
this form).
Nar4 Jeffrey ts'll Name Epstein
Data of Bin Cadre" Pe' -PeatdeTrustorfTrustectameficiary
Ccuntry/Ccontries of Tax Residence
US Virgin Islands
I B s O C n o er m eC a l , a !m ryi g n c P n C •U /1 S C A B a e n n o o t t a a a ./ l S O wner Yee (co le Ayene e 2) No
Feat Name Darren teal "a" Indyke
or
Dale Bre ControThrig Person TyoseRcle Trustee
CoulthletCounines of Tax ReNtYnCe
US
It Controlling Person a non.US
Benoiciaryfnan.US Banetioal Owner Ye, lcomplete Appendix 21 No
at.l Name Last Name
Due a Barth Contra., a Persr.n Type/Rola
Counuyarconv es of Tax Res donee
Is Conlsoihng Person a non.JS
Beneboarenon-US Uncial Onnet7 Yes (compete Apponla 2) Ab
Fest Name Last Nate
Data of 9.1!, CoraoGng PO11100 Tyr-Mole
CountryCounows of Tax Res.:Nees
B is e C ne o f n .c tr i o a l r l y in .b g o P n e .U rs S o n G a e n n t o :S n o .U ar S D arer, Yes (compiele accenex 2) NO
First Nome Name
Date of Bah Cenlrobieg Person Type:Rolm
Cointy/CoanInes of Tax Residence
I O s a C n o ce n i t c r l o a a ry n f g flo P a e -U rs S o n D a e n ro ita n c • l U al S O ence7 yes workologiAsesnox 21 No
Each Controlling Person who is also a non-US Beneficiary/non-US Beneficial Owner must complete and sign
Appendix 2: Beneficiary/Beneficial Owner Self-Certification Form. A Controlling Person who is a Beneficial Owner
with a tax residence solely In the United States is not required to complete and sign Appendix 2.
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if Non-US Bencificiary/Non-US Beneficial Owner is an Individual:
1. I hereby certify that for the purposes of taxation I am not a lax resident in any country other than the countrykountrhaS
indicated above.
2. I confirm that my ownership or other interest in the Entity, if any, .S appropriately aisensed in accordance with
applicable laws and regulations in the countries in which I am lax resident and may be required to be reflected in my
tax filings.
3. I Genf rm that all Income or capital distributions received (or deemed to be receivec for tax purposes) by me from the
Accounts) have been, and going forward will be, taken into account and included in my ielevant lax ffings if required by
the laws of the country (countries) of my tax residence.
If Non-US Beneficiary/Non-US Beneficial Owner s an entity:
1. I hereby certify that for the purposes of taxation the non-US Beneficiary/non-US Beneficial Owner is not a tax resident
in any country other than the county/countries indicated in the self-certification.
2. I confirm that my ownership or other interest in the Entity, if any, is appropriately disclosed in accordance with
applicable laws and regulations in the countries in which I am tax resident and may be required to be reflected in my
tax filings.
3. I confirm that all income or capital distributions received (or deemed to be received for tax purposes) by me from the
Account(s) have been. and will be. taken into account and included In the relevant tax filings if required by the laws of
the country (countries) of tax residence.
I agree that Deutsche Bank may disclose this Certification and any other information related to it or the Aocoun(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) islareAvil 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/or data protection under any applicable laws which might otherwise
preclude the disclosure of such information. I acknowledge that the data protection laws of such other countries may not
afford the information the same protections which if receives in the country in which the Account(s) istareAvill
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 best of my knowledge and belief. correet-and
complete. I undertake to advise Deutsche Bank promptly of any change in *laminae s of which I a <e of and that
causes the information contained herein to become incorrect and to ide Deutsche Ba we suitabl updated
Certification within 30 days of such change in circumstances.
Jeffrey Epstein
Prim Name of Signer tonetbro
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Deutsche Bank
Wealth Management
Client Risk Program --- Guideline
Account Holder Name(s):
erki- 144 - Cri S
Account Number(s):
Ultimate Beneficial Owner(s) (UBO), if
different from Account Holder.
This document is designed to assist the Relationship Manager (RM)/Investment Advisor (IA) in reviewing the
certifications provided by the Account Holder, any Controlling Persons and any Ultimate Beneficial Owners as part of tho
Client Risk Program.
This form should be completed by the RM / IA and submitted together with the Self-Certification as described In the 'CRP
Certification Form Submission' document.
Before providing the Confirmation below, the following factors should be carefully considered:
1. Was any information in the Self-Certification provided by the Account Holder/UBO contradicted by, or Inconsistent with,
information previously provided by the Account Holder/UBO to the RM IA?
2. Is the RM IA aware of any recent change in personal circumstances (e.g. domicile. residence, nationality) of the
Account Holder/UBO without supporting documentation to verify the change having been provided to DB?
If, after considering the factors above (or any other factors or information of which the RM / IA is aware), the RM / IA has
reason to believe the Account Holder/UBO could be engaged in tax evasion, the RM / IA should not provide the
confirmation below and should instead raise the matter with their supervisor.
Relationship Manager/Investment Advisor (RM IA) Affirmation
I confirm that I am not aware of any information that would lead me to conclude that the information provided in the
Self-Certification is incomplete or inaccurate. I understand and acknowledge that if I become aware of any tax compliance
concerns as it relates to the accounts listed above, I will promptly escalate the matter to my supervisor.
eAni(
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Responsible RM I IA Nome
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For internal use only WM187534 023496.031516
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