Court filing — No. 1:20-cv-00658 (Dkt. 132-17, E.D. Va.)

Summary

Exhibit 17, filed May 7, 2021 as Document 132-17 in Case 1:20-cv-00658-LMB-IDD, marked Plaintiff's Trial Exhibit 701 and PX 0109. It contains the State of California purchase order STD. 65 dated Mar 25, 2020, number M12948-T6619, from the Department of General Services, with a required delivery date of Apr 3, 2020. The order covers N95 masks for a total of $476,000,000.00 before tax and $513,961,000.00 with tax, and incorporates the state's general provisions. The exhibit is 6 pages.

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Case 1:20-cv-00658-LMB-IDD Document 132-17 Filed 05/07/21 Page 1 of 6 PageID# 2665
EXHIBIT 17
Case 1:20-cv-00658-LMB-IDD Document 132-17 Filed 05/07/21 Page 2 of 6 PageID# 2666
Plaintiff's Trial Exhibit 701
Exhibit PX 0109
STATE OF CALIFORNIA - GENERAL SERVICES PROCUREMENT DIVISION
PURCHASING AUTHORITY PURCHASE ORDER
STD. 65 (Rev. 10/2019)
Page 1 of 1
DATE: Mar 25, 2020 | AMENDMENT NO.: | PURCHASE ORDER NUMBER: M12948-T6619
SHIP TO: [box crossed out] 01
BILL TO: CA Dept. Of General Services, ATTN: OBAS, 707 Third Street, 2nd Floor, West Sacramento, CA 95605
AGENCY BILLING CODE: 030100 | PURCHASING AUTHORITY NO.:
LEVERAGED PROCUREMENT AGREEMENT NUMBER:
INFORMATION TECHNOLOGY PROJECT IDENTIFICATION NUMBER:
AGENCY OR BUYER INFORMATION
AGENCY TRACKING/REQUISITION NUMBER (Optional):
AGENCY NAME: Department of General Services
CONTACT NAME: Michael Wong
CONTACT E-MAIL ADDRESS: michael.wong@dgs.ca.gov
CONTACT PHONE NUMBER: (916) 441-9619 | CONTACT FAX NUMBER:
TO SUPPLIER ADDRESS: Blue Flame Medical LLC, 499 South Capitol St., SW Suite 420, Washington, DC 20003 US
SUPPLIER CONTACT NAME: John Thomas | SUPPLIER PHONE NUMBER: (818) 636-6522 | SUPPLIER FAX NUMBER: | SUPPLIER E-MAIL ADDRESS: john@blueflame.agency
PAYMENT TERMS: Net 45 | CERTIFICATION NUMBER: | ☐ Certified Small Business ☐ Certified Microbusiness EXPIRATION DATE: | ☐ Certified DVBE EXPIRATION DATE:
SHIPPING INSTRUCTIONS: REQUIRED DELIVERY DATE: Apr 3, 2020 | ☒ F.O.B. Destination FRT. PPD | ☐ F.O.B. Destination FRT. PPD/ADD. Freight not to exceed cost stated on P.O. | ☐ F.O.B. Origin | CITY OF ORIGIN: | STATE: | ZIP CODE:
TERMS AND CONDITIONS
A-1 ☒ General Provisions are incorporated herein by reference to:
☒ Form GSPD - 401 Non-IT Commodities Revision Date: 6/8/2010 OR ☐ Form GSPD - 401IT Revision Date: ______
☐ Attached OR ☐ Published at: www.dgs.ca.gov/pd
A-2 ☐ This order is issued under a Department of General Services (DGS) Leveraged Procurement Agreement (LPA). Terms and Conditions set forth in that agreement (LPA number referenced in the block titled Leveraged Procurement Agreement No.) are incorporated herein by reference as if set forth in full text.
B ☐ Agency Special Provisions are attached and titled ______
C ☐ Any other attachments, such as specifications, Statement of Work, or Information Technology Model Language Modules, are identified in the product or services description area or on continuation pages.
TAXABLE SUBTOTAL: $476,000,000.00
TAX RATE: 7.975%
SALES TAX: $37,961,000.00
INSTALLATION:
SHIPPING FREIGHT:
OTHER NON-TAXABLE:
GRAND TOTAL: $513,961,000.00
PROCUREMENT METHODS
☐ COMPETITIVE: Solicitation Number (if applicable) ______ ☐ LEVERAGED ☐ DVBE / SMALL BUSINESS (GC 14838.5(a)) ☐ NON-COMPETITIVELY BID ☒ EXEMPT
PROGRAM / CATEGORY (Code / Title): | FUND TITLE: | VERIFIED NO STATE SURPLUS AVAILABLE: ☒ YES ☐ NO | PAID BY CAL-CARD: ☐ YES ☒ NO
ITEM | CHAPTER | STATUTE | FISCAL YEAR | OBJECT OF EXPENDITURE (Code and Title) | ☐ Original Equipment ☐ Operating Expense
CERTIFICATION AND APPROVAL OF EXECUTIVE OFFICER
I HEREBY CERTIFY, on personal knowledge, that this order for purchasing the items specified below is issued in accordance with the procedure prescribed by law governing the purchase of such items for the State of California; and that all such legal requirements have been fully complied with.
UNENCUMBERED REMAINDER AFTER POSTING THIS ORDER TO ALLOTMENT EXPENDITURE LEDGER:
ADJUSTMENT INCREASING ENCUMBRANCES:
ADJUSTMENT DECREASING ENCUMBRANCES:
AUTHORIZING NAME: MICHAEL WONG | AUTHORIZING TITLE: Contracts Administrator
AUTHORIZING SIGNATURE: [signature] | CERTIFIED CORRECT SIGNATURE:
ITEM NUMBER | QUANTITY | UNIT | UNSPSC | RECYCLED PRODUCT | PRODUCT OR SERVICE DESCRIPTION | CATEGORY | UNIT PRICE | EXTENSION TOTAL
1 | 100,000 | | | | N95 Masks Model Numbers | Taxable | $4,760.00 | $476,000,000.00
DTC 3B, DTX 3X, L-288, SEKURA-321
QTY 100,000,000, Cost $4.76/ea
COVID19 Prepayment (75%)
DGS2491
Case 1:20-cv-00658-LMB-IDD Document 132-17 Filed 05/07/21 Page 3 of 6 PageID# 2667
Blue Flame Medical LLC
499 South Capitol St., SW Suite 420
Washington, DC 20003 US
Blueflame Medical
INVOICE
BILL TO
Michael Wong
Contracts Administrator
Procurement Division
Department of General Services
State of California
916-441-9619
Michael.Wong@dgs.ca.gov
INVOICE 20032501
DATE 03/25/2020
TERMS Due on receipt
DUE DATE 03/25/2020
DATE | ACTIVITY | DESCRIPTION | QTY | RATE | AMOUNT
03/25/2020 | N95 Masks | N95 Mask Models: DTC 3B, DTX 3X, L-288, SEKURA-321 | 100,000,000 | 4.76 | 476,000,000.00
| Sales Tax | Sales Tax - Zip Code 93725 Rate 7.975% | 1 | 37,961,000.00 | 37,961,000.00
| Shipping | Shipping Cost for 100,000,000 Masks | 1 | 95,200,000.00 | 95,200,000.00
BALANCE DUE $609,161,000.00
Page 1 of 1
DGS2492
Case 1:20-cv-00658-LMB-IDD Document 132-17 Filed 05/07/21 Page 4 of 6 PageID# 2668
DocuSign Envelope ID: 71E6F5C1-15BC-4646-A011-013030F76B43
Reset Form
STATE OF CALIFORNIA-DEPARTMENT OF FINANCE
PAYEE DATA RECORD
(Required when receiving payment from the State of California in lieu of IRS W-9 or W-7)
STD 204 (Rev. 10/2019)
1 INSTRUCTIONS: Type or print the information. Complete all information on this form. Sign, date, and return to the state agency (department/office) address shown in Box 6. Prompt return of this fully completed form will prevent delays when processing payments.
Information provided in this form will be used by California state agencies to prepare Information Returns (Form1099). See next page for more information and Privacy Statement.
NOTE: Governmental entities, i.e. federal, state, and local (including school districts), are not required to submit this form.
2 BUSINESS NAME (As shown on your income tax return): Blue Flame Medical LLC
SOLE PROPRIETOR, SINGLE MEMBER LLC, INDIVIDUAL (Name as shown on SSN or ITIN) Last, First, MI: | E-MAIL ADDRESS: john@blueflame.agency
MAILING ADDRESS: 1146 Central Ave, #441 | BUSINESS ADDRESS: 1146 Central Ave, #441
CITY: Glendale STATE: CA ZIP CODE: 91202 | CITY: Glendale STATE: CA ZIP CODE: 91202
3 PAYEE ENTITY TYPE (CHECK ONE BOX ONLY)
ENTER FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN): 85-0515199
☐ PARTNERSHIP ☐ ESTATE OR TRUST
CORPORATION: ○ MEDICAL (e.g., dentistry, psychotherapy, chiropractic, etc.) ○ LEGAL (e.g., attorney services) ○ EXEMPT (nonprofit) ● ALL OTHERS
NOTE: Payment will not be processed without an accompanying taxpayer identification number.
☐ SOLE PROPRIETOR, INDIVIDUAL, OR SINGLE MEMBER LLC (Disregarded Entity) ENTER SSN OR ITIN: ______
Social Security Number (SSN) or Individual Taxpayer Identification Number (ITIN) are required by authority of California Revenue and Tax Code sections 18646 and 18661)
4 PAYEE RESIDENCY STATUS
☒ CALIFORNIA RESIDENT - Qualified to do business in California or maintains a permanent place of business in California.
☐ CALIFORNIA NON RESIDENT (see next page for more information) - Payments to nonresidents for services may be subject to state income tax withholding.
○ No services performed in California.
○ Copy of Franchise Tax Board waiver of state withholding attached.
5 I hereby certify under penalty of perjury that the information provided on this document is true and correct. Should my residency status change, I will promptly notify the state agency below.
AUTHORIZED PAYEE REPRESENTATIVE'S NAME (Type or Print): John Thomas | TITLE: President | TELEPHONE (include area code): (818) 636-6522
SIGNATURE: DocuSigned by: John Thomas [signature] | DATE: March 24, 2020 | E-MAIL ADDRESS: john@blueflame.agency
6 Please return completed form to:
DEPARTMENT/OFFICE: | UNIT/SECTION:
MAILING ADDRESS: | TELEPHONE (include area code): | FAX:
CITY: | STATE: | ZIP CODE: | E-MAIL ADDRESS:
DGS2493
Case 1:20-cv-00658-LMB-IDD Document 132-17 Filed 05/07/21 Page 5 of 6 PageID# 2669
Chain Bridge Bank
March 16, 2020
Blue Flame Medical LLC
499 S Capitol St, SW, Ste. 420
Washington DC 20003
To whom it may concern,
Please accept this letter as verification of account name, bank routing number, and account number for the following:
Account Name: Blue Flame Medical LLC
Routing Number: 056009479
Account Number: [redacted]
Should you have any additional questions, please do not hesitate to call the bank directly at 703.748.2005.
Sincerely,
[signature]
Maria Cole
Assistant Vice President & Commercial Relationship Manager
Chain Bridge Bank, N.A.
Chain Bridge Bank, N.A. 1445-A Laughlin Avenue McLean, Virginia 22101 703.748.2005
www.chainbridgebank.com
DGS2494
Case 1:20-cv-00658-LMB-IDD Document 132-17 Filed 05/07/21 Page 6 of 6 PageID# 2670
Chain Bridge Bank
Instructions for wiring funds to Chain Bridge Bank, N.A.:
Receiving bank: Chain Bridge Bank, N.A., McLean, VA
Routing/Transit Number: 056009479
For credit to (or Beneficiary): Blue Flame Medical LLC
Beneficiary's account number: [redacted]
Account Type: Checking
Chain Bridge Bank, N.A. 1445-A Laughlin Avenue McLean, Virginia 22101 703.748.2005
www.chainbridgebank.com
DGS2495


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