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Status Declaration Form for Individuals

Regarding U.S. Residency and/or Assets and Income Subject to U.S. Tax1

Declarant2
Family name First name(s)

Date of birth (dd.mm.yyyy) Citizenship(s)3

Permanent residence address (do not use a P.O. box or in-care-of address)

City or town, state or province (include postal code where appropriate) Country

Countries in which resident for tax purposes Tax identification number (if any) for each country4

In order to enable Credit Suisse AG (the “Bank”) to determine the status of the Declarant for purposes of U.S. tax and
securities laws, including but not limited to U.S. withholding tax, as a “Non-U.S. Person” or “U.S. Person”, the Declarant
hereby makes and confirms the following Declarations to the Bank:

1. Status Declaration for Individuals (please tick the appropriate box for each question)

a) Are you currently (or do you plan to be) present in the United States or a U.S. territory for six months or
more per year or six months or more consecutively?? yes no

b) Were you born in the United States or a U.S. territory? yes no

If you were born in the United States or a U.S. territory but nonetheless believe that you are not a “U.S. Person”
under U.S. tax principles, please state the reason and submit written documentation evidencing the relinquishment
or non-acquisition of your U.S. citizen status:
__________________________________________________________________

c) Are you a U.S. citizen (sole or dual citizenship)? yes no

If so, please provide a copy of your current U.S. passport, if available.

d) Are you the holder of an active U.S. Green Card? yes no

Once activated, a U.S. Green Card remains active for U.S. tax purposes (even if the holder resides outside the
U.S. and even if the Green Card itself has expired) until either: (1) it is voluntarily returned to the U.S. immigration
authorities; or (2) it is administratively or judicially revoked by U.S. immigration authorities or a U.S. federal court.

________________________________
1 Investments in U.S. securities may require the submission of additional documentation. In general terms, U.S. securities are equities of U.S. companies, as
well as bonds and investment funds of U.S. issuers. A non-U.S. investment fund (e.g. Luxembourg SICAV) generally is not considered a U.S. security.
2 Each natural person account holder and/or third party beneficial owner or controlling person (if any) must complete a separate declaration as to his/her own status.
3 List all citizenships, if more than one.
4 If you are resident in the U.S. for tax purposes, please provide your TIN in the space provided at question 2.

To be completed by the Bank Signature and stamp of Relationship Manager

01712
082805 Client No. (CIF)
106 303 10.19

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 e) Are you considered a U.S. resident for tax purposes due to the substantial presence test? yes no
You qualify as a U.S. resident for tax purposes if you meet the so-called “substantial presence test.” To meet this test,
you must have been physically present in the United States on at least 31 days during the current year, and 183 days
during the 3 year period that includes the current year and the 2 years immediately before. For details as to how to
count days for these purposes, you should consult the IRS website: http://www.irs.gov/taxtopics/tc851.html

2. US TIN (if applicable)

If you answered “Yes” to any question contained in section 1(c) through 1(e): please provide your U.S.
Individual Taxpayer Identification Number (“TIN”), which is generally your social security number (“SSN”), in the space
below. Please note, a separate information disclosure waiver must also be completed.

TIN: . .
3. General Certifications
The Declarant declares that the information contained on this form, as well as the definitions referred to herein, have
been reviewed and understood, and certifies that the information provided on this form is true, correct and complete.
The Declarant acknowledges and agrees that the Bank can use the signed form to document the
Declarant’s status for all current or future relationships that the Declarant is or will be involved in, in any
capacity, with any Credit Suisse Group Entity in Switzerland.
For the duration of the contractual relationship with the Bank, the undersigned Declarant undertakes to notify
the Bank, at his/her own initiative and within 30 days , if a change of circumstances occurs to his/her status
which causes the information on this form to become incorrect.

The provisions governing choice of law and jurisdiction in the Bank’s General Conditions also apply to this Declaration.

If you have provided a US TIN above, by signing this form, you hereby certify under penalties of perjury that (1) the TIN shown on this
form is my correct TIN; (2) I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not
been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest
or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and (3) I am a U.S. citizen or U.S.
resident alien.

If the IRS has notified you that backup withholding applies to you, you must strike out item (2) in this certification. (The Internal Revenue Service does
not require your consent to any provision of this document other than the certifications required to avoid backup withholding.)

Declarant Confirmation
Place, date Declarant signature

This form is a document as defined in Ar. 110 para. 4 of the Swiss Penal Code (SPC).
Wilfully providing false information when completing this form may result in the penalties set out in Article 251 of the Swiss Penal Code (document forgery,
up to five years’ imprisonment or a fine)

To be completed by the Bank

Client No. (CIF)
106 303 10.19

082805

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