Exhibit B — No. 1:20-cv-00658 (E.D. Va., Dkt. 19-2, filed 07/20/20)
Summary
This is Exhibit B, Document 19-2 in Case 1:20-cv-00658 (Filed 07/20/20), a Chain Bridge Bank Account Agreement dated 03/25/20 for the McLean Branch. The account title is Blue Flame Medical LLC, with Michael C Gula and John S. Thomas listed as signers and one signature required for withdrawal. The non-individual owner section gives the state of organization as DE, a date of organization of 03/23/2020, and the nature of business as medical consulting. The account description is Checking.
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Cite this document
“Exhibit B — No. 1:20-cv-00658 (E.D. Va., Dkt. 19-2, filed 07/20/20).”
Archived at Pandemic Darlings, https://pandemicdarlings.com/source-documents/court-filing-no-1-20-cv-00658-dkt-19-2-e-d-va-e9def3f34c/
, SHA-256 74332098a339dedb0c2f0f96da215626056eee4cab1072d1e415e54ca68a895b.Full text
Case 1:20-cv-00658-LMB-IDD Document 19-2 Filed 07/20/20 Page 1 of 3 PageID#
123
EXHIBIT B
DocuSign Envelope ID: E9274E0D-D915-4ECD-8F10-EED468B56728
Case 1:20-cv-00658-LMB-IDD Document 19-2 Filed 07/20/20 Page 2 of 3 PageID#
Account 124
Agreement Date: 03/25/20
Institution Name & Address Internal Use Easy Business Ck
CHAIN BRIDGE BANK, N.A. Account Title & Address
MCLEAN BRANCH Blue Flame Medical LLC
1445-A LAUGHLIN AVE 499 S Capitol St, SW, Ste 420
Washington DC 20003
MCLEAN, VA 22101
(703) 748-2005
Enter Non-Individual Ow ner Information on page 2. There is additional
Ow ner/Signer Information 1 Ow ner/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 w ithdraw al: 1 .
Address
6128 Edgewood Terrace Signature(s)
Alexandria VA 22307-0000
The undersigned authorize the financial institution to investigate credit
M ailing 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 otherw ise 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- /25 w ithdraw als 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 ow ner(s) agree to the terms of, and
acknow ledge receipt of copy(ies) of, this document and the follow ing:
Employer
Previous
Financial Inst. x Terms & Conditions x Truth in Savings x Funds A vailability
E-M ail mike@gulagraham.com x Electronic Fund Transfers x Privacy x Substitute Checks
Work Phone (202) 255-9745 x Common Features
Home Phone: (202) 255-9745 M obile Phone: (202) 255-9745
Birth Date: /80 SSN/TIN: -2662 A uthorized Signer (See Ow ner/Signer Information for A uthorized
Ow nership of Account Signer Designation(s).)
The specified ow nership w ill 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 w ith Survivorship
X avoid backup w ithholding.
(not as tenants in common)
Joint w ith No Survivorship
{ X
(as tenants in common)
x
Sole Proprietorship or Single Member LLC
LLC-enter tax classification ( C Corp x S Corp
Partnership
Partnership)
(1):
[ X
Michael C Gula
]
C Corporation S Corporation
I.D. # D.O.B.
Trust-Separate A greement Dated:
Beneficiary Designation
(Check appropriate ow nership above.)
(2):
[ X
John S. Thomas
]
Revocable Trust Pay-On-Death (POD) I.D. # D.O.B.
Beneficiary Name(s), Address(es), and SSN(s)
(Check appropriate beneficiary designation above.)
(3):
[ X ]
I.D. # D.O.B.
(4):
[ X ]
I.D. # D.O.B.
Signature Card-VA
Bankers Systems VM P M PM P-LAZ-VA 3/15/2015
Wolters Kluw er Financial Services 2015 Page 1 of 2
DocuSign Envelope ID: E9274E0D-D915-4ECD-8F10-EED468B56728
Case 1:20-cv-00658-LMB-IDD Document 19-2 Filed 07/20/20 Page 3 of 3 PageID#
Ow ner/Signer Information 2 125Non-Individual Ow ner 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
M ailing 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- /24 M ailing 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-M ail mike@gulagraham.com
E-M ail john@blueflame.agency Phone (202) 255-9745
Work Phone EIN: 5199 M obile Phone:
Home Phone: M obile Phone: Account Description Account # Initial Deposit/Source
Birth Date: /85 SSN/TIN: -2005 $
Ow ner/Signer Information 3 Checking 7459 Cash Check
Name
Relationship
Address $
Cash Check
M ailing Address
(if different)
$
Gov' t Issued Photo ID
(type, number, state, Cash Check
issue date, exp. date) - -
Other ID
(description, details) Services Requested
Employer
A TM Debit/Check Cards (No. Requested: )
Previous
Financial Inst.
E-M ail
Work Phone Backup Withholding Certifications
Home Phone: M obile Phone: (If not a "U.S. Person", certify foreign status separately)
Birth Date: SSN/TIN: x By signing signature field (1) on this document, I certify under penalties of perjury that
Ow ner/Signer Information 4 the statements made in this section are true and that I ama U.S. citizen or other U.S. person (as
defined in the instructions).
Name
x Taxpayer I.D. Number - TIN: 5199
Relationship
The Taxpayer Identification Number (TIN) shown is my correct taxpayer identification number.
Address
x Backup W ithholding. I amnot subject to backup withholding either because I have
not been notified that I amsubject to backup withholding as a result of a failure to report all
M ailing Address interest or dividends, or the Internal Revenue Service has notified me that I amno longer subject to
(if different) backup withholding.
Gov' t Issued Photo ID Exempt Recipients. I aman exempt recipient under the Internal Revenue Service
(type, number, state,
issue date, exp. date)
Regulations. Exempt payee code (if any)
Other ID FATCA Code. The FATCA code entered on this form(if any) indicating that I amexempt from
(description, details) FATCA reporting is correct.
Other Terms/Information
Employer
Previous
Financial Inst.
E-M ail
Work Phone
Home Phone: M obile 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 w e 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 VM P M PM P-LAZ-VA 3/15/2015
Wolters Kluw er Financial Services 2015 Page 2 of 2
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