Court filing
Exhibit 110 — USA v. Crowther (Dkt. 136.88)
Filed March 31, 2021 in USA v. Crowther; one of 318 filings from this case.
Record facts
| Court | U.S. District Court for the Middle District of Florida |
|---|---|
| Filed | 2021-03-31 |
U.S. District Court for the Middle District of Florida · No. 2:20-cr-00114 · Doc. 136-88 · 2021-03-31 · Docket on CourtListener
Full text
2630
ACCOUNT AGREEMENT
SANIBB_ CAPTIVA COMMUNITY BANK
1533 HENDRY STREET SUITE 100
FORT MYERS FL 33901
Agreement Date: 04/30/2018 By: KRISTIN DIORIO
(2 EXISTING Account - This agreement replaces previous agreement(s).
Account Description: INV PROP RENTAL INCOME
Checking 0 Savings 0 Now [) 2043 WEST FIRST ST
Initial Deposit $ 100.00 Source: CHECK FORT MYERS FL 33901
Account 29068841
Number:
Account Owner(s) Name & Address
3801 JADE AVENUE LLC
Ownership of Account - CONSUMER (Select One and Initial)
(3 Singie-Party Account C2 Trust-Separate Agreement
(1) Multipte-Party Account
(1 Muttipte-Party Account - Tenancy by the Entireties _
1 other
Rights at Death (Select One and Initial)
Single-Parly Account
Multiple-Party Account With Fight of Survivorship
Multipte-Party Account Without Right of Survivorship
Single-Party Account With Pay On Death
Multiple-Party Account With Right of Survivorship
and Pay On Death
Pay-On-Death Beneficiaries. To Add Pay-On-Death Beneficiaries Name One or More:
Oo0000
Ownership of Account - BUSINESS Purpose
2 Sole Proprietorship (J Single-Member LLC (1 Partnership
LLC (££C tax classification: F] CQopm 0 SQap (0 Pannership)
(1 C Corporation ( S Corporation DC Non-Profit
O
Business: RESIDENTIAL RENTAL INCOME PROPERTY
Backup Withholding Certifications (Non-US. Persons" - Use separate Form W8)
By signing at right. |. STEVEN D ADKINS
certify under penalties of perjury that ihe statements made in this section are true.
Ri TIN: 82-5300988 The Taxpayer Identification
Number (TIN) shown is my correct taxpayer identification number.
Not Subject to Backup Withholding. | am NOT subject to backup
withholding either because | have not been notified thet | am subject to backup
withholding as a result of a failure to report ail interest or dividends, or the interna!
Revenue Service has notified me that | am no longer subject to backup withholding
(2 Exempt Recipient. | am an exempt recipient under (he interna! Revenue
Service Regutations. Exempt payee code (if any)
FATCA Code. The FATCA code entered on this form {if any) indicating that | em
exempt from FATCA reporting is correct.
U.S. Person. | am a U.S. citizen or other U.S. person (as defined
in the instructions).
Additional Information:
Signature({s). The undersigned certifies the accuracy of the information he/she has
provided and acknowledges receipt of a completed copy of this form. The undersigned
authorizes the financial institution to verify credit and employment history and/or have
a credit reporting agency prepare a credit report on the undersigned, as individuals.
The undersigned also acknowledge the receipt of a copy and agree to the terms of the
following agreement(s) and/or disclosures):
Terms & Conditions XJ Truth in Savings Funds Avaitability
®) Gectronic Fund rapsters &] Privacy Substitute Checks
(Common Features / O yan
The internal Revdnue/ Service does pot réquire your consent to any
provision of this ent other than the certifications required to
avoid backup withhglding. P
(1): -
es
al
STEVEN ADKINS ne
1D. # A325-784-67-130-0 D.0B ___04/10/1967
aa
(2): [. C |
CASEY D
LD. # C636-104-85-322-0° pop __09/02/1985
1.0. # 0.0.8.
(4); I x
1D. # 0.0.8.
(J Convenience Account Agent (Single-Party Accounts Only)
Xx
1.0. # 0.0.8.
0473072016
Signature Card-FL.
Bankers Systems™ YVMPS
Wolters Ktuwer Financial Services ©2016
MPSC-LAZ-FL 1/15/2016
Page 3 of 1
EX_110_001
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