Exhibit 23 — No. 1:20-cv-00658 (E.D. Va., Dkt. 132-23, filed 05/07/21)
Summary
This is a signature card in Case 1:20-cv-00658, Document 132-23, marked Exhibit 23 and Defendant's 46, for an Easy Business Ck account at Chain Bridge Bank, N.A., McLean Branch, with an agreement date of 03/25/20. The account title is Blue Flame Medical LLC. Owner/Signer Information names Michael C Gula as a signer, with a stated number of signatures required for withdrawal of 1, and a second page names John S. Thomas as a signer for the non-individual owner. The form also carries a taxpayer certification section and the footer Plaintiff's Trial Exhibit 510.
Summary drafted by a model from the document's text below and checked by script against that text before publication. It is a navigation aid, not a reading of what the document proves. Where AI is used
Cite this document
“Exhibit 23 — No. 1:20-cv-00658 (E.D. Va., Dkt. 132-23, filed 05/07/21).”
Archived at Pandemic Darlings, https://pandemicdarlings.com/source-documents/court-filing-no-1-20-cv-00658-dkt-132-23-e-d-va-ed83e5807c/
, SHA-256 70a1976fca738dde4b1770333848495f0fa85ccacf69f60372dc78c2299dcd03.Full text
Case 1:20-cv-00658-LMB-IDD Document 132-23 Filed 05/07/21 Page 1 of 3 PageID#
2706
EXHIBIT 23
DocuSign Envelope ID: E9274E0D-D915-4ECD-8F10-EED468656728
Case 1:20-cv-00658-LMB-IDD Document 132-23 Filed 05/07/21 Page 2 of 3 PageID#
Account2707
Agreement Date. 03/25/20
Institution Name & Address Internal Use Easy Business Ck
EXHIBIT
CHAIN BRIDGE BANK, N.A. Account Title & Address
exhibitsticker.com
EXHIBIT §
MCLEAN BRANCH Blue Flame Medical LLC t.1
1445-A LAUGHLIN AVE 499 S Capitol St, SW, Ste 420
Washington DC 20003
MCLEAN, VA 22101 Defendant's 46
Defendant's 46 ccd
(703) 748-2005
fir
Enter Non-Individual Owner Information on page 2. There is additional
Owner/Signer Information 1 Owner/Signer Information space on page 2.
Name Michael C Gula ❑ If checked, this is a temporary account agreement.
Relationship Signer Number of signatures required for withdrawal: 1
Address
6128 Edgewood Terrace Signature(s)
Alexandria VA 22307 - 0000
The undersigned authorize the financial institution to investigate credit
Mailing Address
(if different)
6128 Edgewood Terrace and employment history and obtain reports from consumer reporting
Alexandria VA 22307 agency(ies) on them as individuals. Except as otherwise provided by law
Gov't Issued Photo ID Driver's License DL or other documents, each of the undersigned is authorized to make
(type, number, state, 8528
issue date, exp. date) VA - 03/27/17 - 06/24/25 withdrawals from the account(s), provided the required number of
Other ID signatures indicated above is satisfied. The undersigned personally and
(description, details) 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:
Employer
Previous
Financial Inst. E Terms & Conditions El Truth in Savings El Funds Availability
E -Mail mike@gulagraham.com E Electronic Fund Transfers E Privacy N Substitute Checks
Work Phone (202) 255 - 9745 E Common Features ❑
Home Phone: (202) 255-9745 Mobile Phone: (202) 255-9745
Birth Date: /80 SSN/TIN: -2662
❑ Authorized Signer (See Owner/Signer Information for Authorized
Ownership of Account Signer Designation(s).)
The specified ownership will remain the same for all accounts.
• Individual The Internal Revenue Service does not require your consent to any
provision of this document other than the certifications required to
• Joint with Survivorship
avoid backup withholding.
(not as tenants in common) X
• Joint with No Survivorship X
—DoeeSiRned by:
(as tenants in common)
• Sole Proprietorship or Single Member LLC • Partnership (1):
DC4777004F7547D
1:1 LLC-enter tax classification ( • C Corp El S Corp • Partnership)
• C Corporation • S Corporation •
Michael C Gula
I.D. # D.O.B.
• Trust-Separate Agreement Dated:
•
Beneficiary Designation (2):
[X
(Check appropriate ownership above.)
John S. Thomas
• Revocable Trust • Pay-On-Death (POD) I.D. # D.O.B.
•
Beneficiary Name(s), Address(es), and SSN(s) (3):
(Check appropriate beneficiary designation above.)
I.D. # D.O.B.
(4):
I.D. # D.O.B.
Signature Card-VA
Bankers Systems. VMP® M PM P-LAZ-VA 3/15/2015
Wolters Kluwer Financial Services © 2015 Page 1 of 2
Plaintiff's
Trial Exhibit
510
CONFIDENTIAL CBB00000555
DocuSign Envelope ID: E9274E0D-D915-4ECD-8F10-EED468B56728
Case 1:20-cv-00658-LMB-IDD Document 132-23 Filed 05/07/21 Page 3 of 3 PageID#
Owner/Signer Information 2 2708Non-Individual Owner Information
Name John S. Thomas Name Blue Flame Medical LLC
Relationship Signer State/Country & Date DE
of Organization
Address 03/23/2020
Edgehill PL
1415
Pasadena CA 91103-0000 Nature of Business
Mailing Address
1415 Edgehill PL Medical consulting
(if different)
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
issue date, exp. date) CA-08/15/19-06/22/24 Mailing Address 499 S Capitol St, SW, Ste 420
(if different)
Other ID Washington DC 20003
(description, details) Authorization/
Resolution Date
Previous
Employer
Financial Inst.
Previous
Financial Inst.
E-Mail mike@gulagraham.com
E-Mail j ohn@blueflame.agency Phone (202) 255-9745
Work Phone EIN: 5199 Mobile Phone:
Home Phone: Mobile Phone: Account Description Account # Initial Deposit/Source
Birth Dat 2/85 SSN/TIN: -2005
Owner/Signer Information 3 Checking 7459 U Cash U Check
Name
Relationship
$
Address
• Cash U Check
Mailing Address
(if different)
$
Gov't Issued Photo ID
• Cash M Check
(type, number, state,
issue date, exp. date)
Other ID
(description, details) Services Requested
Employer
• ATM U Debit/Check Cards (No. Requested: )
Previous • .
Financial Inst.
E-Mail
• .
Work Phone Backup Withholding Certifications
Home Phone: Mobile Phone: (If not a "U.S. Person", certify foreign status separately)
Birth Date: SSN/TIN:
13 By signing signature field (11 on this document, I certify under penalties of perjury that
Owner/Signer Information 4 the statements made in this section are true and that I am a U.S. citizen or other U.S. person (as
defined in the instructions).
Name
13 Taxpayer I.D. Number - TIN• 5199
Relationship
The Taxpayer Identification Number (TIN) shown is my correct taxpayer identification number.
Address
El Backup Withholding. I am not subject to backup withholding either because I have
not been notified that I 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 I am no longer subject to
(if different) backup withholding.
Gov't Issued Photo ID U Exempt Recipients. I am an exempt recipient under the Internal Revenue Service
(type, number, state,
Regulations. Exempt payee code Of any)
issue date, exp. date)
Other ID
FATCA Code. The FATCA code entered on this form (if any) indicating that I am exempt from
(description, details) FATCA reporting is correct.
Other Terms/Information
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'. VMP® MPMP-LAZ-VA 3/15/2015
Wolters Kluwer Financial Services © 2015 Page 2 of 2
CONFIDENTIAL CBB00000556
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- SHA-256
- 70a1976fca738dde4b1770333848495f0fa85ccacf69f60372dc78c2299dcd03
- Our copy
- 132-att23.pdf
- Original
- No public link identified.