Court filing — No. 1:20-cv-00658 (Dkt. 130-31, E.D. Va.)

Summary

Document 130-31, Case 1:20-cv-00658 (E.D. Va.): a Chain Bridge Bank, N.A. signature card and account agreement, McLean Branch, marked CONFIDENTIAL, dated 03/25/20. The account title is Blue Flame Medical LLC, with the nature of business listed as Medical consulting and a date of organization of 03/23/2020. The owner/signer sections name Michael C Gula and John S. Thomas, and the account description shows Checking. The form states that the number of signatures required for withdrawal is 1.

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DocuSign Envelope ID: E9274E0D-D915-4ECD-8F10-EED468B56728
Case 1:20-cv-00658-LMB-IDD Document 130-31

1Aagreement

Account

Institution Name & Address

CHAIN BRIDGE BANK, N.A.
MCLEAN BRANCH
1445-A LAUGHLIN AVE
MCLEAN, VA 22101

(703) 748-2005

Owner/Signer Information 1

Name Michael C Gula
Relationship Signer
Aceicen 6128 Edgewood Terrace
Alexandria VA 22307-0000
Malling Address 6128 Edgewood Terrace
(if different) i
Alexandria VA 22307
Gov't Issued Photo ID | Driver's License DL
(type, number, state, 8528
issue date, exp. date) = {27/17 -es
Other ID
(description, details)
Employer
Previous
Financial Inst.
E-Mail mike@gulagraham.com
Work Phone (202) 255-9745
Home Phone: (202) 255-9745 Mobile Phone: (202) 255-9745
Birth Date: 80 SSN/TIN: 2662

Ownership of Account
The specified ownership will remain the same for all accounts.
1] Joint with No Survivorship

) Individual
L] Joint with Survivorship

(not as tenants in common) { X

x

(as tenants in common)
L] Sole Proprietorship or Single Member LLC (_] Partnership
LLC-enter tax classification (Cd C Corp S Corp O Partnership)
Oe Corporation Lis Corporation |
O Trust-Separate Agreement Dated:

Beneficiary Designation

(Check appropriate ownership above.)

L_] Revocable Trust

Beneficiary Name(s), Address(es), and SSN{s)

(Check appropriate beneficiary designation above.)

CJ Pay-On-Death (POD)

Filed 05/06/21 Page 2 of 3 PagelD#

Date: 03/25/20

Internal Use Easy Business Ck
Account Title & Address
Blue Flame Medical LLC

499 S Capitol St, SW,
Washington DC 20003

EXHIBIT

Ste 420

Defendant's 46

Enter Non-Individual Owner Information on page 2. There is additional
Owner/Signer Information space on page 2.

C] lf checked, this is a temporary account agreement.

Number of signatures required for withdrawal: 1

Signature(s)

The undersigned authorize the financial institution to investigate credit
and employment history and obtain reports from consumer reporting
agency(ies) on them as individuals. Except as otherwise provided by law
or other documents, each of the undersigned is authorized to make
withdrawals from the account(s), provided the required number of
signatures indicated above is satisfied. The undersigned personally and
as, or on behalf of, the account owner(s) agree to the terms of, and
acknowledge receipt of copy(ies) of, this document and the following:

Funds Availability
Substitute Checks

Truth in Savings
be | Privacy

k] Terms & Conditions
k Electronic Fund Transfers

O

k_] Common Features

(] Authorized Signer (See Owner/Signer Information for Authorized
Signer Designation(s).)

The Internal Revenue Service does not require your consent to any
provision of this document other than the certifications required to
avoid backup withholding.

(1): [, (y~>

DC4777004F7547D

Michael ¢C Gula

1.D. # D.O.B.

John S. Thomas

1.D. # D.O.B.
3):

1.D. # D.O.B.
4):
(4) x

1.D. # D.OB

Signature Card-VA
Bankers Systems ™ VMP@®

Wolters Kluwer Financial Services © 2015

CONFIDENTIAL

MPMP-LAZ-VA 3/15/2015
Page 1 of 2

CBB00000555

§
5
=
a
DocuSign Envelope ID: E9274E0D-D915-4ECD-8F 10-EED468B56728

Owner/Signer Information 2 yg lon-Individual Owner Information
Name John S. Thomas Name Blue Flame Medical LLC
Relationship Signer State/Country & Date DE
of Organization .
Address 1415 Edgehill PL 03/23/2020
Pasadena CA 91103-0000 Nature of Business
Mailing Address 1415 Edgehill PL Medical consulting
(if different) ;
Fees Pasadena CA 91103 Address 499 S Capitol St, SW, Ste 420
Gov't Issued Photo ID | Driver's License DL Washington DC 20003-0000
(type, number, state, 2968 fi
issue date, exp. date) - 8/15/12 4 Mailing Address 499 S Capitol St, SW, Ste 420
(if diff it) '
Other ID ee eesres Washington DC 20003
(description, details) Authorization/
Resolution Date
Empl Previous
mployer Financial Inst
Financial Inst. E-Mail mike@gulagraham.com
E-Mail johneblueflame.agency Phone {202) 255-9745
Work Phone EIN: 5199 Mobile Phone:
Home Phone: Mobile Phone: Account Description| Account # Initial Deposit/Source
Birth Date: 85 SSN/TIN: 2005 $
Owner/Signer Information 3 Checking 7459 C] cash CL] check

Name [|

Relationship

Address

$

Mailing Address

(if different)
$
Gov't Issued Photo ID
(type, number, state, LJ Cash LJ Check
issue date, exp. date) - - |
Other ID .
(description, details) Services Requested
Employer CL ATM oO Debit/Check Cards (No. Requested: )

Financial Inst.

E-Mail L Ll
Work Phone Backup Withholding Certifications

Home Phone: Mobile Phone: (If not a "U.S. Person”, certify foreign status separately)

Birth Date: SSN/TIN: By signing signature field (1) on this document, | certify under penalties of perjury that

Owner/Signer Information 4 the statements made in this section are true and that | ama U.S. citizen or other U.S. person (as

defined in the instructions).
Name

Taxpayer |.D. Number - TIN: _ Rs 1.0°
The Taxpayer Identification Number (TIN) shown is my correct taxpayer identification number.

Relationship

Address
Backup Withholding. | amnot subject to backup withholding either because | have
not been notified that | am subject to backup withholding as a result of a failure to report all
Mailing Address interest or dividends, or the Internal Revenue Service has notified me that | amno longer subject to
(it different) backup withholding.
Gov't Issued Photo ID OO Exempt Recipients. | aman exempt recipient under the Internal Revenue Service

(type, number, state,
issue date, exp. date)
Other ID FATCA Code. The FATCA code entered on this form (if any) indicating that | amexempt from
(description, details) FATCA reporting is correct.

Other Terms/information

Regulations. Exempt payee code (if any)

Employer

Previous
Financial Inst.

E-Mail

Work Phone

Home Phone: Mobile Phone:

Birth Date: SSN/TIN:

Important Account Opening Information. Federal law requires us to
obtain sufficient information to verify your identity. You may be asked
several questions and to provide one or more forms of identification to
fulfill this requirement. In some instances we may use outside sources to
confirm the information. The information you provide is protected by our
privacy policy and federal law.

Signature Card-VA
Bankers Systems '™ VMPO® MPMP-LAZ-VA 3/16/2015
Wolters Kluwer Financial Services © 2015 Page 2 of 2

CONFIDENTIAL CBB00000556


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