Account Agreement, Chain Bridge Bank, N.A. (E.D. Va., Dkt. 38-1, filed 09/29/20)

Summary

This is a Chain Bridge Bank Account Agreement, Document 38-1 in Case 1:20-cv-00658, filed 09/29/20, dated 03/25/20 for the McLean Branch. The account title is Blue Flame Medical LLC, with Michael C Gula and John S. Thomas signing, and one signature is required for withdrawal. The non-individual owner section gives the state of organization as DE, the date as 03/23/2020, and the nature of business as medical consulting. The account description is Checking.

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Full text

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Account Agreement

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
Address

6128 Edgewood Terrace
Alexandria VA 22307-0000

Mailing Address 6128 Edgewood Terrace

(if different) :

Alexandria VA 22307
Gov't Issued Photo ID | Driver's License DL
(type, number, state, 8528

issue date, exp. date}

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.

LJ Joint with Survivorship
(not as tenants in common) { X

LJ Joint with No Survivorship
(as tenants in common)

Xx

L] Sole Proprietorship or Single Member LLC L] Partnership

LLC-enter tax classification (Ld C Corp S Corp LX Partnership)
Lic Corporation Ls Corporation LC
| 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.)

L) Pay-On-Death (POD)

Filed 09/29/20 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

Ste 420

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

[_] If 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
i] Privacy

k] Terms & Conditions
k] Electronic Fund Transfers
k] Common Features LO

L] 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):
(1) x
Michael C Gula
.D. # D.O.B
2):
(2) x :
John Ss. Thomas
|.D. # D.O.B
(3): x ]
|.D. # D.O.B.
4):
(4) x
|.D. # D.O.B.

Signature Card-VA
Bankers Systems™ VMP&
Wolters Kluwer Financial Services © 2015

MPMP-LAZ-VA 3/15/2015
Page 1 of 2
DocuSign Envelope ID: E9274E0D-D915-4ECD-8F 10-EED468B56728

Case 1:20-cv-00658-LMB-IDD —_ Document 38-1 _ Filed 09/29/20 Page 3 of 3 PagelD#
FNon-Individual Owner Information

43) Non-Individual Owner Information

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.

Name John S. Thomas Name Blue Flame Medical LLC
Relationship s igner 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) g .
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) =08/15/19 2 Mailing Address 499 S Capitol St, SW, Ste 420
L * RE (if different) . P
Other ID Washington DC 20003
(description, details} Authorization’
Previous
Employer Financial Inst
Previous inst E-Mail mikeagulagraham.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 [) cash FL] check
Relationship
Address $
Mailing Address LJ
{if different}
$
Gov't Issued Photo ID
issue date, exp. date) - - L]
Other ID 5
(description, details) Services Requested
Employer L] aT L] Debit/Check Cards (No. Requested: )
Financial Inst
E-Mail O O
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
Name defined in the instructions).
Relationship Taxpayer |1.D. Number - TIN: _ E5199
The Taxpayer Identification Number (TIN) shown is my correct taxpayer identification number.
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
(if different) backup withholding.
Gov't Issued Photo ID O Exempt Recipients. | 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 | amexempt 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:

Signature Card-VA
Bankers Systems™ VMP®
Wolters Kluwer Financial Services © 2015

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

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