Preview
FILED: NEW YORK COUNTY CLERK 07/21/2020 06:09 PM INDEX NO. 154000/2018
NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 07/21/2020
NAPOLI
SHKOLNIK PLLC
ATTORNEYS AT LAW
January 15, 2020
PRE 044085
Mahoney & Keane LLP
61 Broadway, Suite 905
New York, NY 10006
Betancourt Van Hemmen Greco & Kenyon LLC
151 Bodman Place, Suite 200
Red Bank, NJ 07701
Re: Darryl Nowak v. Sea Wolf Marine Transportation LLC, et al.,
Dear Counselors:
Pursuant to Betancourt Van Hemmen Greco & Kenyon LLC's demand for authorizations
dated January 3, 2020, enclosed please find authorizations for:
1. SSA-7050-F4;
2. OMB No. 0960-0566; and
3. IRS Form 4506.
Sincerely,
Diane Park
Paralegal
NAPOLILAW.COM
360 LEXINGTON AVENUE, 1ITH FLOOR, NEW YORK. NEW YORK 10017 397-1000
(2I2)
I imiledII hIm Comnm
ANewYoikPinessional
FILED: NEW YORK COUNTY CLERK 07/21/2020 06:09 PM INDEX NO. 154000/2018
NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 07/21/2020
PRE 044085
Betancourt Van Hemmen Greco & Kenyon LLC
151 Bodman Place, Suite 200
Red Bank, NJ 07701
NAPOLlLAW.COM
360 LEX1NGTON AVENUE, 1ITH FLOOR. NEW YORK, NEW YORK 10017 (212)397-1000
ANewYoikProcñ ·n.tl1mol:d I i :bilii)Company
FILED: NEW YORK COUNTY CLERK 07/21/2020 06:09 PM INDEX NO. 154000/2018
NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 07/21/2020
Form SSA-7050-F4 (03-2019) Page 2 of 4
REQUEST FOR SOCIAL SECURITY EARNING INFORMATION
1. Provide your name as it appears on your most recent Social Security card or the name of the individualwhose
earnings you are requesting.
FirstName: D a r r y 1 Middle Initial:
Last Name: N o w a k
Social Number 1 5 o 6 6 7 8 1 One SSN per request
Security (SSN)
Date of Birth: 12/23/1963 Date of Death:
Other Name(s) Used
Maiden Name)
2. What kind of earnings information do you need? (Choose ONE of the following types of earnings or SSA must return
thisrequest.)
Itemized Statement of Earnings $91.00
Requested: 2 0 0 9 to 2 0 1 9
Year(s)
(includes the names and addresses of employers)
If youcheck this tellus you need this Requested: 2 0 0 9 to 2 0 1 9
box, why Year(s)
information below.
Check this box if ou want the earnings
® information CER IFIED foran additional
$34.00 fee.
CertifiedYearly Totals of Earnings $34.00
Year(s) Requested: to
(Does not includethe names and addresses of
employers)Yearly earnings totalsare FREE to thepublicif you
Year(s) Requested: to
do not requirecertification.
To obtain FREE yearlytotalsof
earnings,visitourwebsite at www.ssa.qov/myaccount.
3. If youwould likethisinformation sent to se:::--e:e else, please fill
inthe information below.
I authorize the Social Security Administration to release the earnings information to:
Name Betancourt Van Hemmen Greco & Kenyon LLC
Address 151 Bodman Place, Suite 200 State NJ
Red Bank ZIP Code 07701
City
4. I am the individual towhom the record pertains (or a person authorized to sign on behalf ofthat individual). I
understand that any false representation to knowingly and obtain
willfully information from Social Security records is
punishable by a fine ofnot more than $5,000 or one year inprison.
. . SSA must receive thisform within 120 days from
ignature AND Printed e of Individual or Legal Guardian the date signed
Darryl Nowak
Date ) . 10. 20
tionship (ifapplicable,you must attach proof) Daytime Phone:
Address State
City ZIP Code
0
Witnesses must si n thisform ONLY if theabove signature isby marked (X). If signedby mark (X), two witnesses to the
signin who know he signee must sign below and provide theirfulladdresses. Please printthe signee's name next to the
mark ) on the signature lineabove.
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)
FILED: NEW YORK COUNTY CLERK 07/21/2020 06:09 PM INDEX NO. 154000/2018
NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 07/21/2020
Form 4506 Request for Copy of Tax Retum
(March2019) Þ Do not signthisform unlessall app!iceb!e
lineshave been ccmp|cted. OMB No. 1545-0429
Request may be rejectedif the
form is !ncemp!eteor illegible.
n erna Re enueSce For more idcimation about Form 4506, visitwww.irs.govIform4506.
Tip.You may be able toget yourtaxreturnor return
informationfromothersources.If youhad your taxreturn
completed by a paidpreparer,
they
should be able to
provide you a copyof thereturn.
The IRS canprovidea Tax Return Transcriptformany returns
free of charge.
The transcript
providesmost of theline entries
from the original
tax returnand contains
usually the information
thata thirdparty(suchas a mortgage company)
requires.
See Form 4506-T,Request forTranscript of TaxReturn,or you can quickly
requesttranscripts
by usingour automated service
self-help
Transcript..."
Please visit us at IRS.gov
tools. and clickon "Get a Tax or call 1-800-908-9946.
1a Name shown on taxreturn. enter the name shown
If a joint return, first. 1b Firstsocialsecuritynumber on taxreturn,
taxpayer
Individue! identifk:N number, or
employer number
identification (see instructions)
DarrylNowak
2a If a joint name shown
enter spouse's
return, on tax return. 2b Second social number
security or individual
taxpayer number
identification if joint
taxreturn
3 Currentname, address or suite no.), city,
apt., room,
(including and ZIP code
state, (see instructions)
927 Broadway, Bayonne, NJ 07002
4 Previousaddressshown on the last return filed
if different
fromline 3 (see instructions)
5 If the tax return
is to be mailed to a third
party (such as a mortgage
company),enter the third
party's
name, address,and telephone
number.
BetancourtVan Hemmen Greco & Kenyon LLC,151 Bodman Place,Suite 200, Red Bank,NJ 07701
Caution:If the tax return
is being mailed to a third
party,ensure that
you have filled in lines 6 and 7 before signing. once you
Sign and date the form
have filled
in these these steps
lines. Completing helps to protect
your Once the IRS discloses
privacy. your tax return to the third
party listed
on line
over what the third
5, the IRS has no control party does with the information.
If you would
like to limit the third
party's your retum
to disclose
authority
you can specify
information, this limitation
in your written
agreement with the third
party.
6 Tax returnrequested. Form 1040, 1120, 941, etc.and allattachments as submitted
originally to the IRS, includingForm(s)W-2,
schedules,or amended returns.
Copies ofForms 1040,1040A, and 1040EZ are generally
available
for7 yearsfrom before
filing they are
destroyed by law.Other returnsmay be available
for a longerperiodof time.
Enter onlyone returnnumber. If youneed more than one
typeof return,
you mustcomplete anotherForm 4506.Þ Form 1040
Note:If the copies
mustbe certified
for court
or administrative
proceedings,checkhere . . . . . . . . . . . . . . .
7 Year or periodrequested.Enter the ending
date of the year or period,
using the mm/dd/yyyyformat.
If you are requesting
more than
eight years or periods,
you must attach
anotherForm 4506.
2012 2013 2014 2015
2016 2017 2018
8 Fee. Thereis a $50 fee for each return
requested.Fullpayment must be includedwith your requestor it will
be rejected.Make your check or money order payable to"United StatesTreasury."Enteryour SSN, ITIN,
or EIN and"Form 4506 request" on yourcheck or money order.
a Cost for each return
. . . . . . . . . . . . . . . . . . . . . . . . . . . $ 50.00
b Number of returns
requestedon line 7 .. . . . . . . . . . . . . . . . . . . . . 7
c Totalcost.
Multiplyline 8a by line 8b
. . . . . . . . . . . . . . . . . . . . . . $ 350
9 If we cannot we will refund the fee. If the refund
find the tax retum, shouldgo to the third
party listed
on line 5, check
here . . . . .
Caution:Do not sign this form
unless all applicable
lines have been completed.
Signature I declare that I am either the taxpayer whose name is shown on line 1a or 2a, or a person authorized to obtain the tax return
of taxpayer(s).
requested. If the request applies to a joint return, at least one spouse must sign. If signed by a corporate officer, 1 percent or more shareholder, partner,
managing member, guardian, tax matters partner, executor, receiver, administrator, trustee, or party other than the taxpayer, I certify that I have the authority to
execute Form 4506 on behalf of the taxpayer. Note: This form must be received by IRS within 120 days of the signature date.
Signatory atteststhat he/she has read the attestation clause and upon so reading
declares t t he/she has the to n the Form 4506. See instructions. Phone number on line
of taxpayer
authority
1a or 2a
Sign si re(seeinst/donsF Date
Here
Title (if unela above is a corporation, partnership, estate, or trust)
Spouse's signature Date
For PrivacyActand Paperwork Reduction Act Notice,see page 2. Cat. No. 41721E Form4506 (Rev. 3-2019)
FILED: NEW YORK COUNTY CLERK 07/21/2020 06:09 PM INDEX NO. 154000/2018
NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 07/21/2020
Social Security Administration
Form Approved
Consent for Release of Information OMB No. 0960-0566
You must complete allrequired fields.We willnot honor your request unless allrequired fieldsare completed. (*Signifiesa
required field.
**Please complete these fieldsin case we need to contact you about the consent form).
TO: Social Security Administration
Darryl Nowak 12/23/1963
*My Full Name Date of Birth *My Social Security Number
*My
(MM/DD/YYYY)
I authorize the Social Security Administration to release information or records about me to:
*NAME OF PERSON OR ORGANIZATION: *ADDRESS OF PERSON OR ORGANIZATION:
Betancourt Van Hemmen Greco & Kenyon LLC 151 Bodman Place, Suite 200
Red Bank, NJ 07701
*Iwant this information released because: litigation
We may charge a fee to release information for non-program purposes.
*Please release the fc:|cw|ñg information selected from the listbelow:
Check at least one box. We will not disclose records unless you include date ranges where app!!ceb!ê.
1. Verificationof Social Security Number
2. Current monthly Social Security benefit amount
3. Current monthly Supplemental Security Income payment amount
4. benefit or payment amounts from date 09/12/2017 to date present
My
5. 09/12/2017 present
My Medicare entitlement from date to date
6. Medical records from claims from date09/12/2017 to datepresent
my folder(s)
If youwant us to release a minor child'smedical records, do not use thisform. Instead, contact your local Social
Security office.
7. Complete medical records from my claims folder(s)
8. records" file."
Other record(s)from my file(We will not honor a request for"any and all or "the entire You must specify
other records; e.g.,consultative exams, award/denial notices, benefit applications, appeals, questionnaires,
doctor reports, determinations.)
Application for Disability Insurance Benefits Form SSA-16-BK, Public Disability
Questionnaire Form SSA-546, Disability Report Form SSA-3368-BK
I am the |..d|vidua|,to whom the requested information or record applies, orthe parent or legal guardian of a minor, or the
legal guardian of a legally incompetent adult.I declare under penalty of perjury (28 CFR § 16.41(d)(2004) thatI have examined
allthe information on thisform and itistrue and correct to the best ofmy knce!cdge. I understand that anyone who knowingly
or willfullyseeking or obtaining access to records about another person under false pretenses ispunishable by a fine of up to
$5,000. I also u derstand that I must pay all app!!ceh!e fees for requesting information for a non-program-related purpose.
*Signature: f /|W *Date: I \ O .%©
**Address: 927 Broadway, Bayonne, NJ 07002 **Daytime Phone:212 397 1000
Relationship (ifnot the subject of the record): **Daytime Phone:201 539 0746
Witnesses must sign thisform ONLY if theabove signature isby mark (X). If signedby mark (X),two witnesses to the signing
who know the signee must sign below and provide their fulladdresses. Please printthe signee's name next to the mark (X) on the
signature lineabove.
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)
Form SSA-3288 (11-2016) uf
FILED: NEW YORK COUNTY CLERK 07/21/2020 06:09 PM INDEX NO. 154000/2018
NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 07/21/2020
Form SSA-7050-F4 (03-2019) Page 2 of4
REQUEST FOR SOCIAL SECURITY EARNING INFORMATION
1. Provide your name as it appears on your most recent Social Security card or the name of the individualwhose
earnings you are requesting.
FirstName: D a r r y 1 Middle Initial:
Last Name: N o w a k
Social Number 1 5 0 6 6 7 8 1 5 One SSN per request
Security (SSN)
Date of Birth: 12/23 /1963 Date of Death:
Other Name(s) Used
Maiden Name)
2. What kind of earnings information do you need? (Choose ONE of the following types of earnings or SSA must return
thisrequest.)
Itemized Statement of Earnings $91.00
Year(s) Requested: 2 O 0 9 to 2 0 1 9
(Includes the names and addresses of employers)
If youcheck this tellus you need this Requested: 2 0 0 9 to 2 0 1 9
box, why Year(s)
information below.
Check this box if you want the earnings
information CERTIFIED foran additional
$34.00 fee.
Certified Yearly Totals of Earnings $34.00
Year(s) Requested: to
(Does not includethe names and addresses of
employers)Yearly earnings totalsare FREE to thepublicif you
Year(s) Requested: to
do not requirecertification.
To obtain FREE yearlytotalsof
earnings,visitourwebsite at www.ssa.qov/myaccount.
3. If youwould likethis information sent to sumovna else, please fill
inthe information below.
I authorize the Social Security Administration to release the earnings information to:
Name Mahoney & Keane, LLP
AddresS 61 Broadway, Suite 905 State NY
City New York ZIP Code 10006
4. I am the individual towhom the record pertains (or a person authorized to sign on behalf ofthat individual). I
understand that any false representation to knowingly and obtain
willfully information from Social Security records is
punishable by a fine ofnot more than $5,000 orone year in prison.
. SSA must receive thisform within120 days from
Signature AND Printed Nam of Individual or Legal Guardian the date signed
Darryl Nowak
Date
elationship applicable, you must attach proof) Daytime Phone:
Address State
City ZIP Code
Witnesses must si n thisform ONLY if the
above signature isby marked (X). If signedby mark (X), two witnesses to the
signin who know he signee must sign below and provide theirfulladdresses. Please printthe signee's name next to the
mark ) on the signature lineabove.
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)
FILED: NEW YORK COUNTY CLERK 07/21/2020 06:09 PM INDEX NO. 154000/2018
NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 07/21/2020
Form4506 Request for Copy of Tax Return
(March2019) Þ Do not signthisform unlessall epp!iceb!e
lines
have been completed. OMB No. 1545-0429
Request may be rejectedif the form
is incompleteor illegible.
ÔnÎena ReÓenue
S ice For more informationabout Form 4506, visitwww.irs.gov/form4506.
Tip.You may be able to
get yourtaxreturnor return
information
from othersources.If youhad your taxreturn
completed by a paidpreparer,
they
should be abletoprovideyou a copy of the The
return. IRS can providea Tax Return Transcriptformany returns
freeof charge.The transcript
providesmost of theline entries
from the original
tax returnand contains
usually the information
thata thirdparty(suchas a mortgage company)
requires.
See Form 4506-T, Request forTranscriptof Tax Return,or youcan quicklyrequesttranscripts
by usingourautomated service
self-help
Please visit us at IRS.gov
and click Transcript..."
tools. on "Get a Tax or call 1-800-908-9946.
1a Name shown on tax return.
If a joint
return, enter the name shown
first. 1b Firstsocialsecuritynumber on taxreturn,
individual
taxpayer identification
number, or
employer identificat!en
number (see instructions)
DarrylNowak
2a If a joint enter spouse's
return, name shown on tax return. 2b Second social number
security or !n
taxpayer identificâtian
number tax
if joint return
3 Currentname, address and ZIP code
apt., room, or suite no.), city, state,
(including (see instructions)
927 Broadway, Bayonne, NJ 07002
4 Previousaddressshown on the last return filed if different
fromline 3 (see instructions)
5 If the tax return is to be mailed party (such as a mortgage
to a third company),enter the third
party's
name, address,and telephone
number.
IL:iüiicy& Keane, LLP,61 Broadway, Suite905, New York,New York 10006
Caution: If the tax return is being mailed
to a third ensure that you have filled
party, in lines 6 and 7 before Sign and date the form
signing. once you
have filled
in these these
lines. Completing stepshelps to protect
your privacy.
Once the IRS discloses
your tax return to the third
party listed on line
5, the IRS has no control
over what party does with the information.
the third If you would
like to limit the third
party's your return
to disclose
authority
this limitation
you can specify
information, in your written
agreement with the third
party.
6 Tax returnrequested. Form 1040, 1120, 941, etc.and allattachments as submitted
originally to the IRS, includingForm(s)W-2,
schedules,or amended returns.
Copies ofForms 1040,1040A, and 1040EZ aregenerally for
available 7 yearsfrom before
filing they are
destroyed by law.Other returnsmay be available
for a longer
period Enter
of time. onlyone returnnumber. If youneed more than one
type you must
of return, complete anotherForm 4506.Þ Form 1040
Note: must
If the copies be certified
for court
or administrative
proceedings,checkhere . . . . . . . . . . . . . . .
7 Year or periodrequested.Enter the ending
date of the year or period,
using the mm/dd/yyyyformat.
If you are requesting
more than
you must
eight years or periods, attachanotherForm 4506.
2012 2013 2014 2015 __
2016 2017 2018
8 Fee. There is a $50 fee for each
returnrequested.Fullpayment must be includedwith yourrequest or it will
be rejected.Make your check or money order payableto "UnitedStates Treasury."Enteryour SSN, ITIN,
or EIN and "Form4506 request" on yourcheck or money order.
a Cost for each return
. . . . . . . . . . . . . . . . . . . . . . . . . . . $ 50.00
b Number of returns
requestedon line 7 .. . . . . . . . . . . . . . . . . . . . . 7
c Total cost. line Ba by line 8b
Multiply . . . . . . . . . . . . . . . . . . . . . . $ 350
9 If we cannot we will refund
find the tax return, the fee. If the refund should
go to the third
partylisted on line 5, check
here . . . . .
Caution:Do not sign this form
unlessall applicable
lines have been completed.
Signatureof taxpayer(s).
I declare that I am either the taxpayer whose name is shown on line la or 2a, or a person authorized to obtain the tax return
requested. If the request applies to a joint return, at least one spouse must sign. If signed by a corporate officer, 1 percent or more shareholder, partner,
managing member, guardian, tax matters partner, executor, receiver, administrator, trustee, or party other than the taxpayer, I certify that I have the authority to
execute Form 4506 on behalf of the taxpayer. Note: This form must be received by IRS within 120 days of the signature date.
2 Signatory atteststhat he/she has read the attestation clause and upon so reading
ded&és at he/she has the to si n theForm 4506. See instructions. Phone number on line
of taxpayer
authority
l a or 2a
Sign signature(seeinsroodib$s) Date
Here
Title (if line la above is a corporation, partnership, estate, or trust)
Spouse's signature Date
For PrivacyActand Paperwork ReductionAct Notice,see page 2. Cat. No. 41721E Form4506 (Rev. 3-2019)
FILED: NEW YORK COUNTY CLERK 07/21/2020 06:09 PM INDEX NO. 154000/2018
NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 07/21/2020
Social Security Administration Form Approved
Consent for Release of Information OMB No. 0960-0566
You must complete allrequired fields.We willnot honor your request unless allrequired fieldsare completed. (*Signifiesa
required field.
**Please complete these fieldsin case we need to contact you about the consent form).
TO: Social Security Administration
Darryl Nowak 12/23/1963
*My Full Name Date of Birth *My Social Security Number
*My
(MM/DD/YYYY)
I authorize the Social Security Administration to release information or records about me to:
*NAME OF PERSON OR ORGANIZATION: *ADDRESS OF PERSON OR ORGANIZATION:
Mahoney & Keane, LLP 61 Broadway, Suite 905
New York, New York 10006
*Iwant this information released because: litigation
We may charge a fee to release information for non-program purposes.
*Please release the fõ!!õwing information sê|êcted from the listbelow:
Check at leastone box. We willnot disclose records unless you include date ranges where app!!ceb!e.
1. 2 Verificationof Social Security Number
2. 2 Current monthly Social Security benefit amount
3. Current monthly Supplemental Security Income payment amount
4. payment amounts from date 09/12/2017 to date present
My benefit or
09/12/2017 Present
5. 2 My Medicare entitlement from date to date
6. date09/12/2017 to datepresent
Medical records from my claims folder(s) from
If youwant us to release a minor child'smedical records, do not use thisform. Instead, contact your local Social
Security office.
7. Complete
Preview
FILED: NEW YORK COUNTY CLERK 07/21/2020 06:09 PM INDEX NO. 154000/2018 NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 07/21/2020 NAPOLI SHKOLNIK PLLC ATTORNEYS AT LAW January 15, 2020 PRE 044085 Mahoney & Keane LLP 61 Broadway, Suite 905 New York, NY 10006 Betancourt Van Hemmen Greco & Kenyon LLC 151 Bodman Place, Suite 200 Red Bank, NJ 07701 Re: Darryl Nowak v. Sea Wolf Marine Transportation LLC, et al., Dear Counselors: Pursuant to Betancourt Van Hemmen Greco & Kenyon LLC's demand for authorizations dated January 3, 2020, enclosed please find authorizations for: 1. SSA-7050-F4; 2. OMB No. 0960-0566; and 3. IRS Form 4506. Sincerely, Diane Park Paralegal NAPOLILAW.COM 360 LEXINGTON AVENUE, 1ITH FLOOR, NEW YORK. NEW YORK 10017 397-1000 (2I2) I imiledII hIm Comnm ANewYoikPinessional FILED: NEW YORK COUNTY CLERK 07/21/2020 06:09 PM INDEX NO. 154000/2018 NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 07/21/2020 PRE 044085 Betancourt Van Hemmen Greco & Kenyon LLC 151 Bodman Place, Suite 200 Red Bank, NJ 07701 NAPOLlLAW.COM 360 LEX1NGTON AVENUE, 1ITH FLOOR. NEW YORK, NEW YORK 10017 (212)397-1000 ANewYoikProcñ ·n.tl1mol:d I i :bilii)Company FILED: NEW YORK COUNTY CLERK 07/21/2020 06:09 PM INDEX NO. 154000/2018 NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 07/21/2020 Form SSA-7050-F4 (03-2019) Page 2 of 4 REQUEST FOR SOCIAL SECURITY EARNING INFORMATION 1. Provide your name as it appears on your most recent Social Security card or the name of the individualwhose earnings you are requesting. FirstName: D a r r y 1 Middle Initial: Last Name: N o w a k Social Number 1 5 o 6 6 7 8 1 One SSN per request Security (SSN) Date of Birth: 12/23/1963 Date of Death: Other Name(s) Used Maiden Name) 2. What kind of earnings information do you need? (Choose ONE of the following types of earnings or SSA must return thisrequest.) Itemized Statement of Earnings $91.00 Requested: 2 0 0 9 to 2 0 1 9 Year(s) (includes the names and addresses of employers) If youcheck this tellus you need this Requested: 2 0 0 9 to 2 0 1 9 box, why Year(s) information below. Check this box if ou want the earnings ® information CER IFIED foran additional $34.00 fee. CertifiedYearly Totals of Earnings $34.00 Year(s) Requested: to (Does not includethe names and addresses of employers)Yearly earnings totalsare FREE to thepublicif you Year(s) Requested: to do not requirecertification. To obtain FREE yearlytotalsof earnings,visitourwebsite at www.ssa.qov/myaccount. 3. If youwould likethisinformation sent to se:::--e:e else, please fill inthe information below. I authorize the Social Security Administration to release the earnings information to: Name Betancourt Van Hemmen Greco & Kenyon LLC Address 151 Bodman Place, Suite 200 State NJ Red Bank ZIP Code 07701 City 4. I am the individual towhom the record pertains (or a person authorized to sign on behalf ofthat individual). I understand that any false representation to knowingly and obtain willfully information from Social Security records is punishable by a fine ofnot more than $5,000 or one year inprison. . . SSA must receive thisform within 120 days from ignature AND Printed e of Individual or Legal Guardian the date signed Darryl Nowak Date ) . 10. 20 tionship (ifapplicable,you must attach proof) Daytime Phone: Address State City ZIP Code 0 Witnesses must si n thisform ONLY if theabove signature isby marked (X). If signedby mark (X), two witnesses to the signin who know he signee must sign below and provide theirfulladdresses. Please printthe signee's name next to the mark ) on the signature lineabove. 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) FILED: NEW YORK COUNTY CLERK 07/21/2020 06:09 PM INDEX NO. 154000/2018 NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 07/21/2020 Form 4506 Request for Copy of Tax Retum (March2019) Þ Do not signthisform unlessall app!iceb!e lineshave been ccmp|cted. OMB No. 1545-0429 Request may be rejectedif the form is !ncemp!eteor illegible. n erna Re enueSce For more idcimation about Form 4506, visitwww.irs.govIform4506. Tip.You may be able toget yourtaxreturnor return informationfromothersources.If youhad your taxreturn completed by a paidpreparer, they should be able to provide you a copyof thereturn. The IRS canprovidea Tax Return Transcriptformany returns free of charge. The transcript providesmost of theline entries from the original tax returnand contains usually the information thata thirdparty(suchas a mortgage company) requires. See Form 4506-T,Request forTranscript of TaxReturn,or you can quickly requesttranscripts by usingour automated service self-help Transcript..." Please visit us at IRS.gov tools. and clickon "Get a Tax or call 1-800-908-9946. 1a Name shown on taxreturn. enter the name shown If a joint return, first. 1b Firstsocialsecuritynumber on taxreturn, taxpayer Individue! identifk:N number, or employer number identification (see instructions) DarrylNowak 2a If a joint name shown enter spouse's return, on tax return. 2b Second social number security or individual taxpayer number identification if joint taxreturn 3 Currentname, address or suite no.), city, apt., room, (including and ZIP code state, (see instructions) 927 Broadway, Bayonne, NJ 07002 4 Previousaddressshown on the last return filed if different fromline 3 (see instructions) 5 If the tax return is to be mailed to a third party (such as a mortgage company),enter the third party's name, address,and telephone number. BetancourtVan Hemmen Greco & Kenyon LLC,151 Bodman Place,Suite 200, Red Bank,NJ 07701 Caution:If the tax return is being mailed to a third party,ensure that you have filled in lines 6 and 7 before signing. once you Sign and date the form have filled in these these steps lines. Completing helps to protect your Once the IRS discloses privacy. your tax return to the third party listed on line over what the third 5, the IRS has no control party does with the information. If you would like to limit the third party's your retum to disclose authority you can specify information, this limitation in your written agreement with the third party. 6 Tax returnrequested. Form 1040, 1120, 941, etc.and allattachments as submitted originally to the IRS, includingForm(s)W-2, schedules,or amended returns. Copies ofForms 1040,1040A, and 1040EZ are generally available for7 yearsfrom before filing they are destroyed by law.Other returnsmay be available for a longerperiodof time. Enter onlyone returnnumber. If youneed more than one typeof return, you mustcomplete anotherForm 4506.Þ Form 1040 Note:If the copies mustbe certified for court or administrative proceedings,checkhere . . . . . . . . . . . . . . . 7 Year or periodrequested.Enter the ending date of the year or period, using the mm/dd/yyyyformat. If you are requesting more than eight years or periods, you must attach anotherForm 4506. 2012 2013 2014 2015 2016 2017 2018 8 Fee. Thereis a $50 fee for each return requested.Fullpayment must be includedwith your requestor it will be rejected.Make your check or money order payable to"United StatesTreasury."Enteryour SSN, ITIN, or EIN and"Form 4506 request" on yourcheck or money order. a Cost for each return . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 50.00 b Number of returns requestedon line 7 .. . . . . . . . . . . . . . . . . . . . . 7 c Totalcost. Multiplyline 8a by line 8b . . . . . . . . . . . . . . . . . . . . . . $ 350 9 If we cannot we will refund the fee. If the refund find the tax retum, shouldgo to the third party listed on line 5, check here . . . . . Caution:Do not sign this form unless all applicable lines have been completed. Signature I declare that I am either the taxpayer whose name is shown on line 1a or 2a, or a person authorized to obtain the tax return of taxpayer(s). requested. If the request applies to a joint return, at least one spouse must sign. If signed by a corporate officer, 1 percent or more shareholder, partner, managing member, guardian, tax matters partner, executor, receiver, administrator, trustee, or party other than the taxpayer, I certify that I have the authority to execute Form 4506 on behalf of the taxpayer. Note: This form must be received by IRS within 120 days of the signature date. Signatory atteststhat he/she has read the attestation clause and upon so reading declares t t he/she has the to n the Form 4506. See instructions. Phone number on line of taxpayer authority 1a or 2a Sign si re(seeinst/donsF Date Here Title (if unela above is a corporation, partnership, estate, or trust) Spouse's signature Date For PrivacyActand Paperwork Reduction Act Notice,see page 2. Cat. No. 41721E Form4506 (Rev. 3-2019) FILED: NEW YORK COUNTY CLERK 07/21/2020 06:09 PM INDEX NO. 154000/2018 NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 07/21/2020 Social Security Administration Form Approved Consent for Release of Information OMB No. 0960-0566 You must complete allrequired fields.We willnot honor your request unless allrequired fieldsare completed. (*Signifiesa required field. **Please complete these fieldsin case we need to contact you about the consent form). TO: Social Security Administration Darryl Nowak 12/23/1963 *My Full Name Date of Birth *My Social Security Number *My (MM/DD/YYYY) I authorize the Social Security Administration to release information or records about me to: *NAME OF PERSON OR ORGANIZATION: *ADDRESS OF PERSON OR ORGANIZATION: Betancourt Van Hemmen Greco & Kenyon LLC 151 Bodman Place, Suite 200 Red Bank, NJ 07701 *Iwant this information released because: litigation We may charge a fee to release information for non-program purposes. *Please release the fc:|cw|ñg information selected from the listbelow: Check at least one box. We will not disclose records unless you include date ranges where app!!ceb!ê. 1. Verificationof Social Security Number 2. Current monthly Social Security benefit amount 3. Current monthly Supplemental Security Income payment amount 4. benefit or payment amounts from date 09/12/2017 to date present My 5. 09/12/2017 present My Medicare entitlement from date to date 6. Medical records from claims from date09/12/2017 to datepresent my folder(s) If youwant us to release a minor child'smedical records, do not use thisform. Instead, contact your local Social Security office. 7. Complete medical records from my claims folder(s) 8. records" file." Other record(s)from my file(We will not honor a request for"any and all or "the entire You must specify other records; e.g.,consultative exams, award/denial notices, benefit applications, appeals, questionnaires, doctor reports, determinations.) Application for Disability Insurance Benefits Form SSA-16-BK, Public Disability Questionnaire Form SSA-546, Disability Report Form SSA-3368-BK I am the |..d|vidua|,to whom the requested information or record applies, orthe parent or legal guardian of a minor, or the legal guardian of a legally incompetent adult.I declare under penalty of perjury (28 CFR § 16.41(d)(2004) thatI have examined allthe information on thisform and itistrue and correct to the best ofmy knce!cdge. I understand that anyone who knowingly or willfullyseeking or obtaining access to records about another person under false pretenses ispunishable by a fine of up to $5,000. I also u derstand that I must pay all app!!ceh!e fees for requesting information for a non-program-related purpose. *Signature: f /|W *Date: I \ O .%© **Address: 927 Broadway, Bayonne, NJ 07002 **Daytime Phone:212 397 1000 Relationship (ifnot the subject of the record): **Daytime Phone:201 539 0746 Witnesses must sign thisform ONLY if theabove signature isby mark (X). If signedby mark (X),two witnesses to the signing who know the signee must sign below and provide their fulladdresses. Please printthe signee's name next to the mark (X) on the signature lineabove. 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) Form SSA-3288 (11-2016) uf FILED: NEW YORK COUNTY CLERK 07/21/2020 06:09 PM INDEX NO. 154000/2018 NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 07/21/2020 Form SSA-7050-F4 (03-2019) Page 2 of4 REQUEST FOR SOCIAL SECURITY EARNING INFORMATION 1. Provide your name as it appears on your most recent Social Security card or the name of the individualwhose earnings you are requesting. FirstName: D a r r y 1 Middle Initial: Last Name: N o w a k Social Number 1 5 0 6 6 7 8 1 5 One SSN per request Security (SSN) Date of Birth: 12/23 /1963 Date of Death: Other Name(s) Used Maiden Name) 2. What kind of earnings information do you need? (Choose ONE of the following types of earnings or SSA must return thisrequest.) Itemized Statement of Earnings $91.00 Year(s) Requested: 2 O 0 9 to 2 0 1 9 (Includes the names and addresses of employers) If youcheck this tellus you need this Requested: 2 0 0 9 to 2 0 1 9 box, why Year(s) information below. Check this box if you want the earnings information CERTIFIED foran additional $34.00 fee. Certified Yearly Totals of Earnings $34.00 Year(s) Requested: to (Does not includethe names and addresses of employers)Yearly earnings totalsare FREE to thepublicif you Year(s) Requested: to do not requirecertification. To obtain FREE yearlytotalsof earnings,visitourwebsite at www.ssa.qov/myaccount. 3. If youwould likethis information sent to sumovna else, please fill inthe information below. I authorize the Social Security Administration to release the earnings information to: Name Mahoney & Keane, LLP AddresS 61 Broadway, Suite 905 State NY City New York ZIP Code 10006 4. I am the individual towhom the record pertains (or a person authorized to sign on behalf ofthat individual). I understand that any false representation to knowingly and obtain willfully information from Social Security records is punishable by a fine ofnot more than $5,000 orone year in prison. . SSA must receive thisform within120 days from Signature AND Printed Nam of Individual or Legal Guardian the date signed Darryl Nowak Date elationship applicable, you must attach proof) Daytime Phone: Address State City ZIP Code Witnesses must si n thisform ONLY if the above signature isby marked (X). If signedby mark (X), two witnesses to the signin who know he signee must sign below and provide theirfulladdresses. Please printthe signee's name next to the mark ) on the signature lineabove. 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) FILED: NEW YORK COUNTY CLERK 07/21/2020 06:09 PM INDEX NO. 154000/2018 NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 07/21/2020 Form4506 Request for Copy of Tax Return (March2019) Þ Do not signthisform unlessall epp!iceb!e lines have been completed. OMB No. 1545-0429 Request may be rejectedif the form is incompleteor illegible. ÔnÎena ReÓenue S ice For more informationabout Form 4506, visitwww.irs.gov/form4506. Tip.You may be able to get yourtaxreturnor return information from othersources.If youhad your taxreturn completed by a paidpreparer, they should be abletoprovideyou a copy of the The return. IRS can providea Tax Return Transcriptformany returns freeof charge.The transcript providesmost of theline entries from the original tax returnand contains usually the information thata thirdparty(suchas a mortgage company) requires. See Form 4506-T, Request forTranscriptof Tax Return,or youcan quicklyrequesttranscripts by usingourautomated service self-help Please visit us at IRS.gov and click Transcript..." tools. on "Get a Tax or call 1-800-908-9946. 1a Name shown on tax return. If a joint return, enter the name shown first. 1b Firstsocialsecuritynumber on taxreturn, individual taxpayer identification number, or employer identificat!en number (see instructions) DarrylNowak 2a If a joint enter spouse's return, name shown on tax return. 2b Second social number security or !n taxpayer identificâtian number tax if joint return 3 Currentname, address and ZIP code apt., room, or suite no.), city, state, (including (see instructions) 927 Broadway, Bayonne, NJ 07002 4 Previousaddressshown on the last return filed if different fromline 3 (see instructions) 5 If the tax return is to be mailed party (such as a mortgage to a third company),enter the third party's name, address,and telephone number. IL:iüiicy& Keane, LLP,61 Broadway, Suite905, New York,New York 10006 Caution: If the tax return is being mailed to a third ensure that you have filled party, in lines 6 and 7 before Sign and date the form signing. once you have filled in these these lines. Completing stepshelps to protect your privacy. Once the IRS discloses your tax return to the third party listed on line 5, the IRS has no control over what party does with the information. the third If you would like to limit the third party's your return to disclose authority this limitation you can specify information, in your written agreement with the third party. 6 Tax returnrequested. Form 1040, 1120, 941, etc.and allattachments as submitted originally to the IRS, includingForm(s)W-2, schedules,or amended returns. Copies ofForms 1040,1040A, and 1040EZ aregenerally for available 7 yearsfrom before filing they are destroyed by law.Other returnsmay be available for a longer period Enter of time. onlyone returnnumber. If youneed more than one type you must of return, complete anotherForm 4506.Þ Form 1040 Note: must If the copies be certified for court or administrative proceedings,checkhere . . . . . . . . . . . . . . . 7 Year or periodrequested.Enter the ending date of the year or period, using the mm/dd/yyyyformat. If you are requesting more than you must eight years or periods, attachanotherForm 4506. 2012 2013 2014 2015 __ 2016 2017 2018 8 Fee. There is a $50 fee for each returnrequested.Fullpayment must be includedwith yourrequest or it will be rejected.Make your check or money order payableto "UnitedStates Treasury."Enteryour SSN, ITIN, or EIN and "Form4506 request" on yourcheck or money order. a Cost for each return . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 50.00 b Number of returns requestedon line 7 .. . . . . . . . . . . . . . . . . . . . . 7 c Total cost. line Ba by line 8b Multiply . . . . . . . . . . . . . . . . . . . . . . $ 350 9 If we cannot we will refund find the tax return, the fee. If the refund should go to the third partylisted on line 5, check here . . . . . Caution:Do not sign this form unlessall applicable lines have been completed. Signatureof taxpayer(s). I declare that I am either the taxpayer whose name is shown on line la or 2a, or a person authorized to obtain the tax return requested. If the request applies to a joint return, at least one spouse must sign. If signed by a corporate officer, 1 percent or more shareholder, partner, managing member, guardian, tax matters partner, executor, receiver, administrator, trustee, or party other than the taxpayer, I certify that I have the authority to execute Form 4506 on behalf of the taxpayer. Note: This form must be received by IRS within 120 days of the signature date. 2 Signatory atteststhat he/she has read the attestation clause and upon so reading ded&és at he/she has the to si n theForm 4506. See instructions. Phone number on line of taxpayer authority l a or 2a Sign signature(seeinsroodib$s) Date Here Title (if line la above is a corporation, partnership, estate, or trust) Spouse's signature Date For PrivacyActand Paperwork ReductionAct Notice,see page 2. Cat. No. 41721E Form4506 (Rev. 3-2019) FILED: NEW YORK COUNTY CLERK 07/21/2020 06:09 PM INDEX NO. 154000/2018 NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 07/21/2020 Social Security Administration Form Approved Consent for Release of Information OMB No. 0960-0566 You must complete allrequired fields.We willnot honor your request unless allrequired fieldsare completed. (*Signifiesa required field. **Please complete these fieldsin case we need to contact you about the consent form). TO: Social Security Administration Darryl Nowak 12/23/1963 *My Full Name Date of Birth *My Social Security Number *My (MM/DD/YYYY) I authorize the Social Security Administration to release information or records about me to: *NAME OF PERSON OR ORGANIZATION: *ADDRESS OF PERSON OR ORGANIZATION: Mahoney & Keane, LLP 61 Broadway, Suite 905 New York, New York 10006 *Iwant this information released because: litigation We may charge a fee to release information for non-program purposes. *Please release the fõ!!õwing information sê|êcted from the listbelow: Check at leastone box. We willnot disclose records unless you include date ranges where app!!ceb!e. 1. 2 Verificationof Social Security Number 2. 2 Current monthly Social Security benefit amount 3. Current monthly Supplemental Security Income payment amount 4. payment amounts from date 09/12/2017 to date present My benefit or 09/12/2017 Present 5. 2 My Medicare entitlement from date to date 6. date09/12/2017 to datepresent Medical records from my claims folder(s) from If youwant us to release a minor child'smedical records, do not use thisform. Instead, contact your local Social Security office. 7. Complete