Exhibit 122 — USA v. Crowther (Dkt. 136.100)

Summary

Bank account-opening form for an LLC, marked EX_122 001, Exhibit 122 as Document 136-100 in Case 2:20-cr-00114. The form gives the account type as LLC, the purpose of the account as RENTAL INCOME, an expected average monthly balance of $10,001 - $25,000, and expected ACH and wire activity as DOMESTIC, with a monthly wire frequency of 1-4. The business is shown as registered in LEE COUNTY FLORIDA. The owner entries name STEVEN D ADKINS, employer TARGET ROOFING, occupation VP OF ROOFING CO, and CASEY D CROWTHER, employer TARGET ROOFING, occupation OWNER OF ROOFING CO.

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Case 2:20-cr-00114-JES-M_M Document 136-100

Filed 03/31/21 Page1iofi PagelD

COMMUNITY BANK

Opened By KRISTIN DIIORIO BUSINESS NEW ACCOUNT SCORECARD
5] Date Opened 04/05/2018 = Account # Source of Deposits SALES
8 Initial Deposit 1,000.00 Account Type LLC Purpose of this Acct RENTAL INCOME
YI Expected Avg Monthly Balance $10,001 - $25,000 Expected ACH Activity DOMESTIC
Expected Wire Activity DOMESTIC Monthly ACH Amount $0 - $10,000
Monthly Wire Frequency 1-4 Monthly Cash In/Out Amount $0-$500
Monthly Wire Amount $0 - $10,000 Monthly Cash In/Out Frequency LESS THAN 5
& Business Name 8790 LAREDO LLC New or existing customer? Is there a store front?
2 Tax ID 82-4915465 [x] New [x] Yes
w| Physical Address 2043 WEST FIRST ST C4 a C4
wl FORTMYERS _FL._ 33904 Existing No
B State Where Registered LEE COUNTY FLORIDA Internet Gambling Business?
©! Description of Business CO G OOFING [ Yes ifyes, DO NOT OPEN.
Primary Trade Area STATE [x] No
Own/Maintain ATMs? Non-Profit or Charity?

OWNER/SIGNER/BENEF OWNER OWNER/SIGNER/BENEF OWNER

If yes, customer must provide @ copy of the

If yes, a copy of the IRS 501C Designation must be forwarded to BSA Department.

[ | Yes

LI Yes Processor or iSO Agreement AND a copy of the
[x] No ATM equipment Sale or Lease Agreement.
Forward documentation to the BSA department.

If yes, how does the entity receive contributions?
No

The Bank DOES NOT Open Money Service Business Accounts.
Contact BSA Department if the customer provides any of the following services.

[| Cash Checks [ ] Sell Lottery Tickets [| Gaming Activities i.e. Bingo [ ] Currency Exchanges/Dealers
(| Money Order Sales [| Prepaid Card Sales [_] Third Party Payment Processor [ ] Exchange of Virtual Currency
[| Traveler Check Sales [| Money Transmitter

Name STEVEN D ADKINS DOB 04/10/1967

Tax ID 287-54-5858 Phys. Address 17651 WELLS RD

Residency Status US Citizen N FORT MYERS FL 33917
Citizenship United States Primary !D Drivers License

Employer TARGET ROOFING Secondary ID Other

Occupation VP OF ROOFING CO

Is customer a Politically Exposed Person (Senior Political Figure, Member of a Senior Political Figure's immediate family, or a close
associate of a Senior Foreign Political figure?)

[x] No [| Yes If yes, explain

Name CASEY D CROWTHER DOB 09/02/1985

Tax ID 593-88-8937 Phys. Address 3950 WILLIAMSON RD
Residency Status US Citizen FORT MYERS FL. 33905
Citizenship United States Primary ID Drivers License

Employer TARGET ROOFING Secondary ID Other

Occupation OWNER OF ROOFING CO

Is customer a Politically Exposed Person (Senior Political Figure, Member of a Senior Political Figure’s immediate family, or a close
associate of a Senior Foreign Political figure?)

[x] No [ | Yes If yes, explain

EX_122 001


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