Curlin_-_Preliminary_Questionnaire_and_Registration_Form.pdf

BIDDER REGISTRATION FORM

INSTRUCTIONS: Upon completion of this Bidder Registration Form please print, sign, and send a pdf copy, along with the required copy of a Government issued ID for the Bidder or Control Person(s) of the Bidder, to AFDComplexAssets@usdoj.gov. ALL REQUESTED INFORMATION IS REQUIRED. ANSWER “YES” or “NO” wherever possible. If an item does not apply, please indicate so by writing “NONE” or “N/A.”

SECTION 1: Identification and Disclosures

1A: Bidder Identification: Please provide the following identifying information for the bidder. The bidder identified in this section will appear on the bill of sale.

Name of Bidder:

Type of Legal Entity (if applicable):

Mailing Address:

Taxpayer ID Number (EIN or SSN):

(Indicate country of origin if outside the US)

Description of Current Business:

Telephone Number:

E-Mail Address:

1B: Control Persons of Bidder: For non-publicly traded entities, please provide the name, position, home address, tax identification number, and date of birth (or date of incorporation) of each person (or other legal entity) whom, since January 1, 2010, is or was an Officer, member of the Board of Directors, member of the governing board, a principal, trustee, and/or owner of Bidder. Owner means any person who directly or beneficially owns or owned 5% or more of the Bidder’s voting equity on a fully diluted (as if exercised) basis. For publicly traded companies, this information is not required. Additional paper may be used if necessary.

Name Position (i.e. Officer, Director, principal, shareholder)

Address (Street, City, State)

Tax ID Number (EIN or SSN)

Date of Birth/ Incorporation mailto:AFDComplexAssets@usdoj.gov

1C: Bank Account Information: Please provide identifying information about the account that will be used to pay both the registration deposit and, if selected, the purchase price. You must authorize the below institution to release information related to the ownership and account balance to the United States Marshals Service. The funds available in the account must be sufficient to cover your anticipated bid price.

Bank Name

Bank Address

ABA Number

Account Number

Contact Name

Phone Number

I authorize the above financial institution to release my account balance and beneficial ownership information to the Asset Forfeiture Division, United States Marshals Service.

Name Signature Date

If you are submitting your deposit by wire transfer please use the following instructions:

ABA:

ALC:

Federal Reserve Bank of New York 33 Liberty Street New York, NY 10045

Please include the following in the description field: 09-FBI-007717 + Name of Bidder

If you are submitting your deposit by cashier’s check, please send the check to:

FEDEX or UPS

USPS

1E: Buyer’s Contact with Certain Persons

Please describe any contact, communication or other relationships between the Bidder and/or any Control Person with William Gallion, or anyone whom you know to be acting on behalf of William Gallion:

Section 2 - Certification

Subject to Section 1001 of Title 18 of the United States Code, which provides a criminal penalty for persons making materially false statements to the United States, I hereby submit this form to the United States Marshals Service and do declare and attest that all of the statements and representations contained herein are truthful, accurate, and complete. I understand that my bidder registration is not complete until all required documentation and the deposit have been received by the USMS.

PLEASE TAKE TIME TO REVIEW YOUR ANSWERS AND MAKE CERTAIN THAT

YOU HAVE ACCURATELY COMPLETED EACH SECTION

Signature

Printed Name

Date