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Filing # 99216609 E-Filed 11/20/2019 05:49:11 PM
IN THE CIRCUIT COURT 5™
JUDICIAL CIRCUIT, IN AND FOR
MARION COUNTY, FLORIDA
JESUS SANTIAGO, CASE NO.: 2019-CA-2229
Plaintiff,
vs.
MICHAEL OWENS HERLONG,
Defendant.
/
REQUEST TO PRODUCE
The Defendant, MICHAEL OWENS HERLONG, by and through the undersigned
attorneys, and in accordance with Florida Rule of Civil Procedure 1.350(a) request that Plaintiff,
JESUS SANTIAGO, produce the following for inspection and/or copying within thirty (30) days
of the date of service hereof:
1. Copies of Federal Income Tax Returns, W-2 withholding tax statements, and any
and all other business records and/or income records, and other evidence of income for three years
prior to the incident and all subsequent years, together with evidence of current income to date.
2. In the event and only in the event that copies of Federal Income Tax Returns, W-2
withholding tax statements, and any and all other business records and/or income records are not
available from the Plaintiff, counsel for Plaintiff or certified public accountant of the Plaintiff or
other business consultant, the Plaintiff should complete and execute an authorization form and
return to counsel for the Defendant to allow the Defendant to obtain IRS records directly from the
Internal Revenue Service.
3. A copy of the driver's license in the possession of the Plaintiff at the time of the
incident alleged.
4 Any and all hospital, physician, medical reports and/or records, and related bills,
paid or owing, allegedly resulting from the accident or occurrence.
Electronically Filed Marion Case # 19CA002229AX 11/20/2019 05:49:11 PM5 Any and all hospital, physician or medical reports rendered by any health care
provider of the Plaintiff together with any written reports rendered by any expert retained including
any accident reconstruction expert applicable to any and all issues in this cause.
6 Any and all written reports rendered by any expert retained by Plaintiff, including
any accident reconstruction expert, consulting expert physician, or any other expert retained in this
cause.
7 Any and all written or recorded statements taken from parties or witnesses
concerning any issue in this cause.
8 Any and all photographs, graphs, charts and other documentary evidence of the
scene, parties or vehicles involved in or pertaining to the subject accident, occurrence or issues in
this cause.
9. Bills and/or estimates or repair to the vehicle and/or damaged property and the cost
of temporary or permanent replacement thereof, including rental vehicle charges.
10. Any and ail insurance policies providing benefits or coverage to the Plaintiff for
any claimed injury or damage from the subject accident or occurrence.
11, All documents reflecting any and all Workers’ Compensation claims filed by
Plaintiff.
12, All documents reflecting any and all traffic citations, tickets, warrants for arrest and
the like issued to Plaintiff.
13. All documents reflecting any and all lawsuits which name Plaintiff as a party.
14. Copies of any other bills and/or receipt of any other payments for out-of-pocket
expenses claimed as a result of the accident or incident.
15. All business records, including the books and records of the business,
proprietorship or corporation and pay receipts, other memoranda in the possession, custody or
control of the Plaintiff indicating gross income for self-employment, salary, commissions,
bonuses, overages, credits, and reimbursements for business expenses from the beginning of the
current calendar year to thirty (30) days prior to the time of trial.
16. Statements retained by you, your attorney or investigators of independent witnesses
bearing knowledge of facts relevant and material to the claims and defenses in the instant litigation,
to be produced prior to any deposition of any said persons.17. All of the tangible things within the possession, custody or control of the Plaintiff
herein upon which the claims and defenses herein are based and specifically, but not limited to,
writings, drawings, drafts, charts, photographs, movies, slides, film, videotapes, phono records,
and other recording devices, instruments, equipment, real and personal property, objects, goods
and/or vehicles or operations which are the subjects of the claims and defenses herein so that the
same may be inspected, copied, tested, measured, surveyed and/or photographed pursuant to Rule
1.350 of the Florida Rules of Civil Procedure and which said items are not specifically identified
by another paragraph of the Request to Produce.
18. Traffic or other court transcripts involving the subject matter of the instant
litigation.
19, Any and all releases, covenants not to sue, Mary Carter or Mary Carter type
agreements to withhold execution and/or execute against one defendant first entered into between
the Plaintiff and any other defendant, person, individual, insurance company, firm or corporation
who you contend may be responsible for the subject accident or incident.
20. All ordinances, regulations, rules, statutes, customs, practices and publications
upon which your claims and counter defenses are made and based upon.
21. — All documents and items specified in your Answer to Interrogatories as coming
with Rule 1.340(c) of the Florida Rules of Civil Procedure, exercising the option to produce
records in lieu of compilation or summary based on said records and reports.
22. Copies of any and all reports written and/or prepared by experts.
23. Copies of all Letters of Protection provided to any health care provider or entity.
24, If any of the documents encompassed by this request for production of documents
is/are deemed by you to be privileged, furnish all non-privileged documents and provide a log
outlining all documents claimed as privileged which includes: (1) the type of privilege claimed for
each document; 2) a brief description of the document; 3) the author of the document sufficient to
identify it; 4) the recipient (if any); 4) the date of the document.
25. Signed authorization, original attached with pleading, requesting Social Security
records,
26. All photographs of Plaintiff that depict all injuries alleged by Plaintiff as a result of
the accident in question.27. All photographs and /or videos depicting the Plaintiff while on any and all
vacations, excursions, trips, events or travel subsequent to the accident in question.
28. Any and all applications, records, determinations of eligibility for disability
benefits, whether Social Security, or private disability insurance.
29. Any and all settlement demands submitted on behalf of the Plaintiff seeking
compensation for personal injury as a result of any incident other than the subject motor vehicle
accident including but not limited to any demand letter related to any other motor vehicle accident,
work accident, or other accident or incident from which Plaintiff has claimed to have sustained a
personal injury.
30. Any and all gym membership agreements giving Plaintiff access to its facilities
within the last five (5) years.
31, Any and all documents reflecting Plaintiff's request for special accommodations as
a result of any claimed injuries from the subject accident at any workplace and/or to any employer
since the subject accident.
32. Any and all records pertaining to payments made to the Plaintiff arising from the
subject accident pursuant to:
a. the United States Social Security Act; any federal, state or local disability
act; or any other public programs providing medical expenses, disability
payments or other similar benefits;
b. any health, sickness or disability income insurance, and any other similar
benefits;
c. any contract or agreements of any group, organization, partnership or
corporation to provide, pay for, or reimburse costs of hospital, medical or
other health care services;
d. any contractual or voluntary wage contribution plan provided by any
employers of the Plaintiff or any other system intended to provide wages
during any period of alleged disability of such individual.
33. Copies of any and all health insurance cards for any health insurance provider for
the Plaintiff at the time of the accident in question, and all subsequent health insurance providers.34. Any and all documents from Plaintiffs health insurer indicating payment for
medical treatment relating to the injuries Plaintiff claims to have sustained from the accident in
question.
35. Copies of any and all lien letters or other statements asserting or alleging the
existence of a lien by any medical providers and/or insurers for services received.
CERTIFICATE OF SERVICE
I HEREBY CERTIFY that a true and correct copy of the foregoing was furnished by
electronic mail via the Court’s E-Portal to all known designated addresses for Michael J. Smith,
Esq., MORGAN & MORGAN, P.A., Alftorneys for Plaintiff; MSmith@forthepeople.com,
ECannon@forthepeople.com thisD day of November 2019.
CAMERON, HODGES. COLEMAN,
LaPOINTE & WRIGHT, P.A.
Vv ~ WRIGHT, III, ESQ.
Florida Bar No. 993141
CHRISTOPHER C. COLEMAN, ESQ.
Florida Bar No. 0716359
1820 SE 18th Avenue
Ocala, Florida 34471
Phone (352) 351-1119 (al)
Fax (352) 351-0151
Designated Electronic Mail:
Servicevww@cameronhodges3.com
Attorney for Defendant4506-T Request for Transcrlpt of Tax Return
Form > Donot sign this form unless ali applicable Ines Have been completed, OMB No. 1845-4078
See tse Teamty > Request muy be rejected if the form Is moompleto ar iMegible.
Kntrdemaaéaues” | > For more information about Form 4608-7, vel wwz.lrgovlformaO6t,
‘Tip. Use Form 4508-T to order a iransorlpt or other return information free of charye, Bee the produot list below. You oan quickly request transoripte by using
‘our automated self-help service tools, Please vist ys at JAS.gov and allck pn "Get a Tax Transoript.,.” under "Toots" or oall 1-800-208-9946, ifyou need a copy
‘Of your Fetutn, Use Form 4506, Request for Copy of Tax Return, There Is a feo to gat a copy of your return,
ta Name shown on tax retum, if a Joint return, entor the name ‘th First octal ‘number on tax return, Individual a dendlfication
* shown fet, 8 ‘Hinbor ov cover anieeton sonar ae ai
2a If @Jolnt return, enter spouse's name shown on tax refurn, 2b Svoond social seourity number or individual taxpayer
identification number If joint tax return
3 Gurrant nario, address (including apt, robm, or suite no,), city, state, and ZIP oodé (eee lnstrugtions)
4 Pravious addresa Bhown on the leet relurn fled f different from line & (eee Inetruotions)
5. lf the fransotipt or tax Information Is ta be malted to a third party (such as a mortgage company), enter the third party's name, address,
and telephone number,
‘Caution: If the tax transoript ls being malied to a third Parly, enaure that you have filled In fines 6 through 9 befare signing. Sign and date the form once
‘you have filled tn these lines. Complating these steps helps to protect your privacy, Onoe the IRS dleolgees your tax trangoript to the third party listed
on line 6 the IRS has no contra} over what the third party doas with the Information. If you would like to limit the third pariy’s authority to disclose your
‘traneoript Information, you can specify this {imitation In your wrltten agraement with the third party.
8 — Transoript requested, Enter the tax form number here (1040, 1086, 1120, oto) and check the appropriate bax below, Enter only ons tax form.
number per request. >
@ Return Transcript, which inoludes mont of the line Hema of @ tax‘ratum as tiled with the IRS, A tax retumn transorlpt does not reflect
changes made to the account after the return s proosssed, Transcripts ara only available for the following returns: Form 1040 series,
Form 1085, Form 1120, Form 1420-A, Form 1120-H, For 1420-L, and Form 11208, Rotum transorlpts are avaliable for the currant year
and retuma processed duting the prior 3 processing years, Most requests will be processed within 70 business days... 4, 5 y
1b Acnount Transeript, which contains Information on the finenolel slalus of the acoount, auch as payments made on the account, penalty
assessments, and adjustments made by you or the IRS after the return was fled, Retutn information |e Emited to Items suoh as tax flability
and estimated tax payments, Account transoripts are available for most retums. Most requests will be processed within 10 businesa days,
© Record of Account, whloh provides the most dotalted Information as It Is a combination of the Retun ‘Transoript and the Aogount
‘Trensoript, Avallable for current year and 3 prior tax years, Most requests willi be processed within 10 buamess dae... ke
7 Verlfloation of ontlling, which fe proof from the IRS that you did not file a return for the year, Gurrent year requests are only avaliable
after June 1th, There are no availablity restrlotions on prior year requests, Most requests wil be proopased within 10 business days.
8 Form W-2, Form 1099 serise, Form 1098 serfes, or Form 8498 serles transorlpt, The IAS can provide a transaript that Includes data from
these Information returns. State or looal information Is not Included with the Form W-2 information, ‘The IRS may be able to provide this
tranaatlpt Information for up to 10 years, Information for the ourrent year |s generally not avallablo until the year after it ls fed with the IRS. For
‘example, W-2 Information for 2011, filed in 2012, wit Ikely not bs available fram tha IRS unt 2013, If you need W-2 Information for retirement
Purposes, you should contant the Soolal Seuurlty Administration at 1-800-772-1213, Most requests will bs processed within 10 business days. [}
Gautiots If you need a copy of Form W-2 or Form 1089, you should first contact the payer. To got a copy of the Form W-2 or Form 1098 filed
‘with your return, you must use Form 4506 and request a copy of your return, which Inoludes all attachments,
Gao oO
9 — Year or perlod requested. Enter the date of the year or parlod, using the mm/dd/yyyy format. If you are requesting more than four
years or perlods, you must attach another Form 4506-7. For requests relating to quarterly tax returns, such as Form 941, you must enter
Sach quarter or tax pettod separately, l / / I ye of | / 7 I / /
‘Caution: Do not sign this form unites all appticable fines have bean oompletact,
‘Signature of taxpayer(o), | declare that | am elther the taxpayer whose name Is shown on tina ta or 2a, or & person authorized to obtaln the tax
Information fequested, If the request appliss io a jolnt return, at least one spouse must sign, If signed by a corporate officer, 1 percent or more
ler, pe managing member, guardian, tax_matters partner, executor, receiver, administrator, trustee, or parly other than the taxpayer, }
carthy that! 16 the authority to exeoute Form 4608-T on behalf of the taxpayer. Note: This form must be reoelved by IRS within 120 days of the
ignature date,
‘Signatory atteste that he/she has read the attestation ciause and upon so reading declares that he/she if
Farts culty lecignne rere aeee te eeeweation cau Fang umber oF taxpayer on tine
|
) ‘Signature (ee instructions}. ° Dale
Sign
Here Tille {ifline 4a above Is a corporation, partnership, calate, or trusty
) Spouse’s signature . Date
For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat, No. 87687N Form 4606-T (Rev, 7-2017)‘Form S8A.7080 (10-2018) - . o . Page 2 of 4
REQUEST FOR SOGIAL SECURITY EARNING INFORMATION — .
1. Provide your name as it appears on your most recent Social Security card or the name of the Individual whose
' earnings you are requesting. . .
First Name: . Middle Initial: ]
Last Name: :
“Social Security Number (SSN) - -f One SSN per-request
Date of Birth: n atl Date of Death: tpl e PE PT
Other Name(s) Used wf Coat .
Maiden Name). Jt v : :
2. What kind of earnings information do you need? (Choose ONE of tha following types of earnings or SSA must retum
this request.) so . : . sot . .
- [J Hemized Statement of Earnings $91.00 Year(s) Requested: |” to
(Includes the names and addresses of employers) : : . =
IFyou check this box, tell us why you need this Information below. . ~ Years) Requesied: “ee to
; Oo Check thls box if yau want the earnings information ~
: CERTIFIED for an additional $34.00 fee. *
(C] Cortitiag Yearly Totats of Earnings $34.00. gars) Requested:
(Does nat include the names and addresses of .
employers) Yearly earnings totals are. FREE to the public if you Year(s) Requested: 7 to
do not require certification. To obtain FREE yearly totals of
earnings, visit our website at.
3. If you would like this information sent to someone else, please fill in the information below.
| authorize the Social Security Administration to release the earnings information to:
Name
Address . ;- OO * {Slate
ciy - wae Re, ‘ .. {ZIP Code
4, tam the individual to whom the record pertains (or a person authorized to sign on behalf of that Individual). T
understand that any false representation to knowingly and willfully obtain information ftom Social Security records is
* punishable by a fine of not more than-$5,000 or oné year in prison. .
Signature AND Printed Name of Individual or Legal Guardian [SSA mustrecalve this form within 120 days from the dale Sed
Date ye
Relationship (if applicable, you must attach proof) : . Daytime Phone:
Address ‘ Se State -
city : ZIP Code
Witnesses must sign this form ONLY if the above signature Is by marked (X). If signed by mark (X), wo witnesses to the Signing Who
know the signee must sign below and provide their full addresses. Please print the signee's name next to the mark (X) on the signature
line above, . :
1, Signature of Witness 2, Signature of Witness
- “Address (Number and Street, City, State and ZIP Code) Address (Number and Street, City, State and ZIP Code}
Preview
Filing # 99216609 E-Filed 11/20/2019 05:49:11 PM IN THE CIRCUIT COURT 5™ JUDICIAL CIRCUIT, IN AND FOR MARION COUNTY, FLORIDA JESUS SANTIAGO, CASE NO.: 2019-CA-2229 Plaintiff, vs. MICHAEL OWENS HERLONG, Defendant. / REQUEST TO PRODUCE The Defendant, MICHAEL OWENS HERLONG, by and through the undersigned attorneys, and in accordance with Florida Rule of Civil Procedure 1.350(a) request that Plaintiff, JESUS SANTIAGO, produce the following for inspection and/or copying within thirty (30) days of the date of service hereof: 1. Copies of Federal Income Tax Returns, W-2 withholding tax statements, and any and all other business records and/or income records, and other evidence of income for three years prior to the incident and all subsequent years, together with evidence of current income to date. 2. In the event and only in the event that copies of Federal Income Tax Returns, W-2 withholding tax statements, and any and all other business records and/or income records are not available from the Plaintiff, counsel for Plaintiff or certified public accountant of the Plaintiff or other business consultant, the Plaintiff should complete and execute an authorization form and return to counsel for the Defendant to allow the Defendant to obtain IRS records directly from the Internal Revenue Service. 3. A copy of the driver's license in the possession of the Plaintiff at the time of the incident alleged. 4 Any and all hospital, physician, medical reports and/or records, and related bills, paid or owing, allegedly resulting from the accident or occurrence. Electronically Filed Marion Case # 19CA002229AX 11/20/2019 05:49:11 PM5 Any and all hospital, physician or medical reports rendered by any health care provider of the Plaintiff together with any written reports rendered by any expert retained including any accident reconstruction expert applicable to any and all issues in this cause. 6 Any and all written reports rendered by any expert retained by Plaintiff, including any accident reconstruction expert, consulting expert physician, or any other expert retained in this cause. 7 Any and all written or recorded statements taken from parties or witnesses concerning any issue in this cause. 8 Any and all photographs, graphs, charts and other documentary evidence of the scene, parties or vehicles involved in or pertaining to the subject accident, occurrence or issues in this cause. 9. Bills and/or estimates or repair to the vehicle and/or damaged property and the cost of temporary or permanent replacement thereof, including rental vehicle charges. 10. Any and ail insurance policies providing benefits or coverage to the Plaintiff for any claimed injury or damage from the subject accident or occurrence. 11, All documents reflecting any and all Workers’ Compensation claims filed by Plaintiff. 12, All documents reflecting any and all traffic citations, tickets, warrants for arrest and the like issued to Plaintiff. 13. All documents reflecting any and all lawsuits which name Plaintiff as a party. 14. Copies of any other bills and/or receipt of any other payments for out-of-pocket expenses claimed as a result of the accident or incident. 15. All business records, including the books and records of the business, proprietorship or corporation and pay receipts, other memoranda in the possession, custody or control of the Plaintiff indicating gross income for self-employment, salary, commissions, bonuses, overages, credits, and reimbursements for business expenses from the beginning of the current calendar year to thirty (30) days prior to the time of trial. 16. Statements retained by you, your attorney or investigators of independent witnesses bearing knowledge of facts relevant and material to the claims and defenses in the instant litigation, to be produced prior to any deposition of any said persons.17. All of the tangible things within the possession, custody or control of the Plaintiff herein upon which the claims and defenses herein are based and specifically, but not limited to, writings, drawings, drafts, charts, photographs, movies, slides, film, videotapes, phono records, and other recording devices, instruments, equipment, real and personal property, objects, goods and/or vehicles or operations which are the subjects of the claims and defenses herein so that the same may be inspected, copied, tested, measured, surveyed and/or photographed pursuant to Rule 1.350 of the Florida Rules of Civil Procedure and which said items are not specifically identified by another paragraph of the Request to Produce. 18. Traffic or other court transcripts involving the subject matter of the instant litigation. 19, Any and all releases, covenants not to sue, Mary Carter or Mary Carter type agreements to withhold execution and/or execute against one defendant first entered into between the Plaintiff and any other defendant, person, individual, insurance company, firm or corporation who you contend may be responsible for the subject accident or incident. 20. All ordinances, regulations, rules, statutes, customs, practices and publications upon which your claims and counter defenses are made and based upon. 21. — All documents and items specified in your Answer to Interrogatories as coming with Rule 1.340(c) of the Florida Rules of Civil Procedure, exercising the option to produce records in lieu of compilation or summary based on said records and reports. 22. Copies of any and all reports written and/or prepared by experts. 23. Copies of all Letters of Protection provided to any health care provider or entity. 24, If any of the documents encompassed by this request for production of documents is/are deemed by you to be privileged, furnish all non-privileged documents and provide a log outlining all documents claimed as privileged which includes: (1) the type of privilege claimed for each document; 2) a brief description of the document; 3) the author of the document sufficient to identify it; 4) the recipient (if any); 4) the date of the document. 25. Signed authorization, original attached with pleading, requesting Social Security records, 26. All photographs of Plaintiff that depict all injuries alleged by Plaintiff as a result of the accident in question.27. All photographs and /or videos depicting the Plaintiff while on any and all vacations, excursions, trips, events or travel subsequent to the accident in question. 28. Any and all applications, records, determinations of eligibility for disability benefits, whether Social Security, or private disability insurance. 29. Any and all settlement demands submitted on behalf of the Plaintiff seeking compensation for personal injury as a result of any incident other than the subject motor vehicle accident including but not limited to any demand letter related to any other motor vehicle accident, work accident, or other accident or incident from which Plaintiff has claimed to have sustained a personal injury. 30. Any and all gym membership agreements giving Plaintiff access to its facilities within the last five (5) years. 31, Any and all documents reflecting Plaintiff's request for special accommodations as a result of any claimed injuries from the subject accident at any workplace and/or to any employer since the subject accident. 32. Any and all records pertaining to payments made to the Plaintiff arising from the subject accident pursuant to: a. the United States Social Security Act; any federal, state or local disability act; or any other public programs providing medical expenses, disability payments or other similar benefits; b. any health, sickness or disability income insurance, and any other similar benefits; c. any contract or agreements of any group, organization, partnership or corporation to provide, pay for, or reimburse costs of hospital, medical or other health care services; d. any contractual or voluntary wage contribution plan provided by any employers of the Plaintiff or any other system intended to provide wages during any period of alleged disability of such individual. 33. Copies of any and all health insurance cards for any health insurance provider for the Plaintiff at the time of the accident in question, and all subsequent health insurance providers.34. Any and all documents from Plaintiffs health insurer indicating payment for medical treatment relating to the injuries Plaintiff claims to have sustained from the accident in question. 35. Copies of any and all lien letters or other statements asserting or alleging the existence of a lien by any medical providers and/or insurers for services received. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing was furnished by electronic mail via the Court’s E-Portal to all known designated addresses for Michael J. Smith, Esq., MORGAN & MORGAN, P.A., Alftorneys for Plaintiff; MSmith@forthepeople.com, ECannon@forthepeople.com thisD day of November 2019. CAMERON, HODGES. COLEMAN, LaPOINTE & WRIGHT, P.A. Vv ~ WRIGHT, III, ESQ. Florida Bar No. 993141 CHRISTOPHER C. COLEMAN, ESQ. Florida Bar No. 0716359 1820 SE 18th Avenue Ocala, Florida 34471 Phone (352) 351-1119 (al) Fax (352) 351-0151 Designated Electronic Mail: Servicevww@cameronhodges3.com Attorney for Defendant4506-T Request for Transcrlpt of Tax Return Form > Donot sign this form unless ali applicable Ines Have been completed, OMB No. 1845-4078 See tse Teamty > Request muy be rejected if the form Is moompleto ar iMegible. Kntrdemaaéaues” | > For more information about Form 4608-7, vel wwz.lrgovlformaO6t, ‘Tip. Use Form 4508-T to order a iransorlpt or other return information free of charye, Bee the produot list below. You oan quickly request transoripte by using ‘our automated self-help service tools, Please vist ys at JAS.gov and allck pn "Get a Tax Transoript.,.” under "Toots" or oall 1-800-208-9946, ifyou need a copy ‘Of your Fetutn, Use Form 4506, Request for Copy of Tax Return, There Is a feo to gat a copy of your return, ta Name shown on tax retum, if a Joint return, entor the name ‘th First octal ‘number on tax return, Individual a dendlfication * shown fet, 8 ‘Hinbor ov cover anieeton sonar ae ai 2a If @Jolnt return, enter spouse's name shown on tax refurn, 2b Svoond social seourity number or individual taxpayer identification number If joint tax return 3 Gurrant nario, address (including apt, robm, or suite no,), city, state, and ZIP oodé (eee lnstrugtions) 4 Pravious addresa Bhown on the leet relurn fled f different from line & (eee Inetruotions) 5. lf the fransotipt or tax Information Is ta be malted to a third party (such as a mortgage company), enter the third party's name, address, and telephone number, ‘Caution: If the tax transoript ls being malied to a third Parly, enaure that you have filled In fines 6 through 9 befare signing. Sign and date the form once ‘you have filled tn these lines. Complating these steps helps to protect your privacy, Onoe the IRS dleolgees your tax trangoript to the third party listed on line 6 the IRS has no contra} over what the third party doas with the Information. If you would like to limit the third pariy’s authority to disclose your ‘traneoript Information, you can specify this {imitation In your wrltten agraement with the third party. 8 — Transoript requested, Enter the tax form number here (1040, 1086, 1120, oto) and check the appropriate bax below, Enter only ons tax form. number per request. > @ Return Transcript, which inoludes mont of the line Hema of @ tax‘ratum as tiled with the IRS, A tax retumn transorlpt does not reflect changes made to the account after the return s proosssed, Transcripts ara only available for the following returns: Form 1040 series, Form 1085, Form 1120, Form 1420-A, Form 1120-H, For 1420-L, and Form 11208, Rotum transorlpts are avaliable for the currant year and retuma processed duting the prior 3 processing years, Most requests will be processed within 70 business days... 4, 5 y 1b Acnount Transeript, which contains Information on the finenolel slalus of the acoount, auch as payments made on the account, penalty assessments, and adjustments made by you or the IRS after the return was fled, Retutn information |e Emited to Items suoh as tax flability and estimated tax payments, Account transoripts are available for most retums. Most requests will be processed within 10 businesa days, © Record of Account, whloh provides the most dotalted Information as It Is a combination of the Retun ‘Transoript and the Aogount ‘Trensoript, Avallable for current year and 3 prior tax years, Most requests willi be processed within 10 buamess dae... ke 7 Verlfloation of ontlling, which fe proof from the IRS that you did not file a return for the year, Gurrent year requests are only avaliable after June 1th, There are no availablity restrlotions on prior year requests, Most requests wil be proopased within 10 business days. 8 Form W-2, Form 1099 serise, Form 1098 serfes, or Form 8498 serles transorlpt, The IAS can provide a transaript that Includes data from these Information returns. State or looal information Is not Included with the Form W-2 information, ‘The IRS may be able to provide this tranaatlpt Information for up to 10 years, Information for the ourrent year |s generally not avallablo until the year after it ls fed with the IRS. For ‘example, W-2 Information for 2011, filed in 2012, wit Ikely not bs available fram tha IRS unt 2013, If you need W-2 Information for retirement Purposes, you should contant the Soolal Seuurlty Administration at 1-800-772-1213, Most requests will bs processed within 10 business days. [} Gautiots If you need a copy of Form W-2 or Form 1089, you should first contact the payer. To got a copy of the Form W-2 or Form 1098 filed ‘with your return, you must use Form 4506 and request a copy of your return, which Inoludes all attachments, Gao oO 9 — Year or perlod requested. Enter the date of the year or parlod, using the mm/dd/yyyy format. If you are requesting more than four years or perlods, you must attach another Form 4506-7. For requests relating to quarterly tax returns, such as Form 941, you must enter Sach quarter or tax pettod separately, l / / I ye of | / 7 I / / ‘Caution: Do not sign this form unites all appticable fines have bean oompletact, ‘Signature of taxpayer(o), | declare that | am elther the taxpayer whose name Is shown on tina ta or 2a, or & person authorized to obtaln the tax Information fequested, If the request appliss io a jolnt return, at least one spouse must sign, If signed by a corporate officer, 1 percent or more ler, pe managing member, guardian, tax_matters partner, executor, receiver, administrator, trustee, or parly other than the taxpayer, } carthy that! 16 the authority to exeoute Form 4608-T on behalf of the taxpayer. Note: This form must be reoelved by IRS within 120 days of the ignature date, ‘Signatory atteste that he/she has read the attestation ciause and upon so reading declares that he/she if Farts culty lecignne rere aeee te eeeweation cau Fang umber oF taxpayer on tine | ) ‘Signature (ee instructions}. ° Dale Sign Here Tille {ifline 4a above Is a corporation, partnership, calate, or trusty ) Spouse’s signature . Date For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat, No. 87687N Form 4606-T (Rev, 7-2017)‘Form S8A.7080 (10-2018) - . o . Page 2 of 4 REQUEST FOR SOGIAL SECURITY EARNING INFORMATION — . 1. Provide your name as it appears on your most recent Social Security card or the name of the Individual whose ' earnings you are requesting. . . First Name: . Middle Initial: ] Last Name: : “Social Security Number (SSN) - -f One SSN per-request Date of Birth: n atl Date of Death: tpl e PE PT Other Name(s) Used wf Coat . Maiden Name). Jt v : : 2. What kind of earnings information do you need? (Choose ONE of tha following types of earnings or SSA must retum this request.) so . : . sot . . - [J Hemized Statement of Earnings $91.00 Year(s) Requested: |” to (Includes the names and addresses of employers) : : . = IFyou check this box, tell us why you need this Information below. . ~ Years) Requesied: “ee to ; Oo Check thls box if yau want the earnings information ~ : CERTIFIED for an additional $34.00 fee. * (C] Cortitiag Yearly Totats of Earnings $34.00. gars) Requested: (Does nat include the names and addresses of . employers) Yearly earnings totals are. FREE to the public if you Year(s) Requested: 7 to do not require certification. To obtain FREE yearly totals of earnings, visit our website at. 3. If you would like this information sent to someone else, please fill in the information below. | authorize the Social Security Administration to release the earnings information to: Name Address . ;- OO * {Slate ciy - wae Re, ‘ .. {ZIP Code 4, tam the individual to whom the record pertains (or a person authorized to sign on behalf of that Individual). T understand that any false representation to knowingly and willfully obtain information ftom Social Security records is * punishable by a fine of not more than-$5,000 or oné year in prison. . Signature AND Printed Name of Individual or Legal Guardian [SSA mustrecalve this form within 120 days from the dale Sed Date ye Relationship (if applicable, you must attach proof) : . Daytime Phone: Address ‘ Se State - city : ZIP Code Witnesses must sign this form ONLY if the above signature Is by marked (X). If signed by mark (X), wo witnesses to the Signing Who know the signee must sign below and provide their full addresses. Please print the signee's name next to the mark (X) on the signature line above, . : 1, Signature of Witness 2, Signature of Witness - “Address (Number and Street, City, State and ZIP Code) Address (Number and Street, City, State and ZIP Code}