Certification of Beneficial Owners of Legal Entities, Blue Flame Medical LLC (E.D. Va., Dkt. 160-6)

Summary

This is a Chain Bridge Bank Certification of Beneficial Owners of Legal Entities form, filed as Document 160-6 in Case 1:20-cv-00658 and stamped CBB00000566 to CBB00000568. The form explains that federal regulation requires financial institutions to obtain and record information about the beneficial owners of legal entity customers. It names Blue Flame Medical LLC as the entity, with Michael C Gula, CEO, as the person opening the account. It lists John Thomas and Michael Gula as beneficial owners, each with an ownership figure of 50.00, and Gula as the individual with significant responsibility for managing the entity.

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Docusign EnveleRe! SOLEV-D0658-~LMB4DD pocument 160-6 Filed 05/27/21 Page 2 of 5 PagelD#

4219
Certification of Beneficial Owners of Legal Entities

The information contained in this Certification is sought pursuant to Section 1020.230
of Title 31 of the United States Code of Federal Regulations (31 CFR 1020.230).

Financial Institution Name: Financial Institution Location:

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

Financial Institution Contact Person: Contact Phone Number: Customer Portfolio/Identifier:
Mariano Castagnello (703) 748-2005 PF

/. General Instructions

What is this form?

To help the government fight financial crime, Federal regulation requires certain financial institutions to obtain, verify,
and record information about the beneficial owners of legal entity customers. Legal entities can be abused to disguise
involvement in terrorist financing, money laundering, tax evasion, corruption, fraud, and other financial crimes.
Requiring the disclosure of key individuals who own or control a legal entity (i.e., the beneficial owners) helps law
enforcement investigate and prosecute these crimes.

Who has to complete this form?

This form must be completed by the person opening a new account on behalf of a legal entity with any of the
following U.S. financial institutions: (i) a bank or credit union; (ii) a broker or dealer in securities; (iii) a mutual fund;
(iv) a futures commission merchant; or (v) an intfoducing broker in commodities.

For the purposes of this form, a legal entity includes a corporation, limited liability company, or Other entity that is
created by a filing of a public do¢ument with a Secretary of State,or similar office, a general partnership, and any
similar business entity formed in the United States or a foreign country. Legal entity does not include sole
proprietorships, unincorporated associations, or natural persons Opening accounts on their own behalf.

What information do | have to provide?

This form requires you to provide the name, address, date of birth and Social Security numberor passport number or
other similar information, in the case of Non-U.S)persomis) for the following individWial§ (ie. , the beneficial owners):

(i) Each individual, if any, who owns, directly or indirectly, 25 percent or more of the equity interests of
the legal entity customer (e.g., each natural person that owns 25 percent or more of the shares of a
corporation); and

(ii) An individual with significant responsibility for managing the legal entity customer (e.g., a Chief Executive
Officer, Chief Financial Officer, Chief Operating Officer, Managing Member, General Partner, President, Vice
President, or Treasurer).

The number of individuals that satisfy this definition of "beneficial owner" may vary. Under section (i), depending on
the factual circumstances, up to four individuals (but as few as zero) may need to be identified. Regardless of the
number of individuals identified under section (i), you must provide the identifying information of one individual under
section (ii). It is possible that in some circumstances the same individual might be identified under both sections (e.g.,
the President of Acme, Inc. who also holds a 30% equity interest). Thus, a completed form will contain the identifying
information of at least one individual (under section (ii)), and up to five individuals (i.e., one individual under section
(ii) and four 25 percent equity holders under section (i)). The financial institution may also ask to see a copy of a
driver’s license or other identifying document for each beneficial owner listed on this form.

Certification of Beneficial Owners with Verification CERT-BEN-V 8/1/2019
© 2019 Wolters Kluwer Financial Services, Inc. (1908).00
All rights reserved. Page 1 of 4

CONFIDENTIAL CBB00000566
Filed 05/27/21 Page 3 of 5 PagelD#

4220

Il. Certification of Beneficial Owner(s)

Persons opening an account on behalf of a legal entity must provide the following information:

Title of Natural Person Opening Account:
CEO

Full Name of Natural Person Opening Account:
Michael C Gula

Type of Legal Entity for Which the Account is Being Opened:
LLC

Name of Legal Entity for Which the Account is Being Opened:
Blue Flame Medical LLC

Legal Entity Identifier (Optional):

Physical Address of Legal Entity for Which the Account is Being Opened:
499 S Capitol St, SW, Ste 420 Washington DC 20003

Account Number (Optional):

Provide the following information for each individual, if any, who, directly or indirectly, through any contract,

Account Type (Optional):
Easy Business Ck

arrangement, understanding, relationship or otherwise, owns 25 percent or more of the equity interests of the
legal entity listed above:

Full Name Date of Address (Residential or Business For U.S. For Non-U.S. Persons:
(Beneficial Owner) Birth Street Address) Persons: Social Security
Social Number, Passport
Ownership nem similar identification
(Optional) number?
First Mil. Street Number
John 1415@B@dgehill PL
Last Suffix City Country of Issuance
Thomas 50.00 '% | Pasadena
State & Zip
CA ‘91103
First M.I. Street Number
Michael 6128 Eagewood Terrace
06/24/80 PF
Last Suffix City Country of Issuance
Gula 50.00 %|Alexandria
State & Zip
VA 22307
First M.I. Street Number
Last Suffix City Country of Issuance
%
State & Zip
First M.I. Street Number
Last Suffix City Country of Issuance
%
State & Zip

_] If checked, Beneficial Owner listing requirement is Not Applicable

Certification of Beneficial Owners with Verification
© 2019 Wolters Kluwer Financial Services, Inc.
All rights reserved.

CONFIDENTIAL

CERT-BEN-V 8/1/2019
(1908).00
Page 2 of 4

CBB00000567
DocuSian Envslgea! ELEY O0O56-EMB4DD Document 160-6 Filed 05/27/21 Page 4 of 5 PagelD#

A
Il. Certification of Beneficial Owner(s), Continued

Provide the following information for one individual with significant responsibility for managing the legal entity
listed above, such as:
@ An executive officer or senior manager (e.g., Chief Executive Officer, Chief Financial Officer,
Chief Operating Officer, Managing Member, General Partner, President, Vice President,
Treasurer); or
¢@ Any other individual who regularly performs similar functions.
(If appropriate, an individual listed under the ownership section above may also be listed in the section below).

Full Name/Title Date of Address (Residential or Business For U.S. For Non-U.S. Persons:
(of Person Birth Street Address) Persons: Social Security
with Control) Social Number, Passport
Security Number and country
Number of issuance, or other
similar identification
number!
First M.1. Street Number
Michael 6128 Edgewood Terrace
Last Suffix City Country of Issuance
Gula Alexandria
State & Zip
Title VA 22307
CEO

! In lieu of a passport number, Non-U.S. Persons may also provide a Social Security Number, an alien identification card number, or number and country of
issuance of any other government-issued document evidencing nationality or residence and bearing a photograph or similar safeguard.

I, Michael C Gulla (name of natural person opening account),
hereby certify, to the best of my knowledge, that the information provided aboye is completejand correct. Also,
the Legal Entity named above agrees to notify the Financial Institution of any change in the beneficial ownership

information on this Certification. DocuSigned by:
. 5 2020

For Institution Use Only:

Name of Type of Document Document |ID Place of Issuance Date of Expiration
Beneficial Owner Number i lSsuance Date
Thomas GPL —
OTHER 08/15/2019 06/22/2024
Michael TAXID
Gula a
(JDL 03/27/2017 06/24/2029
OTHER
O
Gula a
OTHER
Certification of Beneficial Owners with Verification CERT-BEN-V 8/1/2019
© 2019 Wolters Kluwer Financial Services, Inc. (1908).00

All rights reserved. Page Sof 4

CONFIDENTIAL CBB00000568


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