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Filing # 157928132 E-Filed 09/22/2022 10:41:52 AM
IN THE CIRCUIT COURT OF THE
FOURTH JUDICIAL CIRCUIT, IN AND FOR
DUVAL COUNTY, FLORIDA
CASE NO.: 16-2022-CA-004328
DIVISION: CV-G
CLARENCE MITCHELL,
Plaintiff,
vs.
VICTORIA NIKALE GREEN, an individual,
JULENE TURBEVILLE, an individual, and
LINDSAY TYLER DENNIS, an individual,
Defendants.
DEFENDANT LINDSAY TYLER DENNIS’
REQUEST FOR PRODUCTION TO PLAINTIFF.
TO Clarence Mitchell
c/o Jessica L. Lanifero, Esquire
Morgan & Morgan, P.A.
501 Riverside Avenue, Suite 1200
Jacksonville, FL 32202
Defendant, Lindsay Tyler Dennis, pursuant to Rules 1.280 and 1.350, Florida Rules of
Civil Procedure, requests that you produce to Defendant’s undersigned attorneys, at their law
offices at 4811 Beach Boulevard, Suite 303, Jacksonville, FL 32207, certain items for inspection
and copying. Defendant requests that you produce the following:
1 All of your hospital and medical records (including x-ray, MRI, and CT scan films)
and reports regarding the injuries which you claim to have sustained as a result of
the accident alleged in your Complaint.
All of your hospital, medication, and medical bills regarding the injuries you claim
Page 1 of 4
ACCEPTED: DUVAL COUNTY, JODY PHILLIPS, CLERK, 09/22/2022 11:58:22 AM
to have sustained as a result of the accident alleged in your Complaint.
All other bills or documentary evidence of expenses which you claim to be related
to, and caused by, the accident alleged in your Complaint.
All medical records, and records of other healthcare providers from doctors,
hospitals or anyone else, who has rendered healthcare treatment to you for any
injury or medical condition that pre-existed the accident described in the
Complaint, but alleged to have been aggravated by the accident.
If you have applied for and/or received Medicare benefits, please sign the
authorization, original attached, requesting Medicare records.
If you have applied for and/or received Medicaid benefits, please sign the
authorization, original attached, requesting Medicaid records.
All federal income tax returns and all W-2 forms for the time period beginning five
years before the accident described in the Complaint and continuing to the present,
plus all records of earnings to date for this year.
Signed authorizations, originals (two) attached, requesting federal income tax
records for the time period beginning five years before the accident.
Photographs and negatives purporting to show your injuries, your automobile
following the accident alleged in your Complaint, or the scene of the accident
alleged in the Complaint.
10. A copy of the enrollment card, membership verification, or other documentation
indicating any medical insurance coverage.
ll All documents identified in your answers to interrogatories.
12. Photocopies of any driver’s licenses you hold or any other form of photographic
identification.
13 All documents evidencing payment of medical bills or lost earnings by collateral
sources or evidencing attempts by you to obtain payment from sources other than
this Defendant.
14 All estimates and bills for repair of any damage to the vehicles as a result of the
accident that is alleged in your Complaint.
15, All recorded, written, or transcribed statements made by witnesses to the accident
alleged in your Complaint.
Page 2 of 4
16 Signed authorization, original attached, requesting Social Security records.
17 If you have ever served in any branch of the military, please sign the authorization,
original attached, requesting military records.
18 Copies of all letters of protection, doctor’s lien, forbearance agreements, or any
similar documents you or your attorney has executed in favor of any
medical/healthcare provider.
19. All notices of lien that you have received from any entity for any reason.
In support of this request for production, Defendant states that the items listed above are in
the possession, custody, and control of Plaintiff, that those items constitute or contain matters
within the scope of Rule 1.280(b), Florida Rules of Civil Procedure, that Defendant needs those
items in the preparation of this case, and that Defendant is unable, without undue hardship, to
obtain the substantial equivalent of those items by other means.
O'HARA LAW FIRM,
Professional Association
feo
Brian M. Guter
Florida Bar No, 113681
Michael P. Regan, Jr.
Florida Bar No. 20311
4811 Beach Boulevard, Suite 303
Jacksonville, FL 32207
Telephone (904) 346-3166
Facsimile (904) 346-5445
Service E-Mail: eService @ oharalawfirm.com
Attorneys for Lindsay Tyler Dennis
Page 3 of 4
CERTIFICATE OF SERVICE
I HEREBY CERTIFY that a copy hereof has been furnished to Jessica L. Lanifero,
Esquire, Morgan & Morgan, P.A., 501 Riverside Avenue, Suite 1200, Jacksonville, FL 32202, via
e-service at jlanifero@forthepeople.com, cfitslaff@ forthepeople.com and
mjohnson
@ forthepeople.com and to Kendra B. Therrell, Esquire, Law Offices of Kubicki Draper,
76 South Laura Street, Suite 1400, Jacksonville, FL 32202, via e-service at
KBT-KD @kubickidraper.com, mpanganiban
@ forthepeople.com and rkisling@forthepeople.com
and to E. Holland Howanitz, Esquire, Wicker Smith O’Hara Mccoy & Ford P.A., 50 North Laura
Street, Suite 2700, Jacksonville, FL 32202, via e-service at JAXcrtpleadings@wickersmith.com
on this 22™ day of September, 2022.
b20x
Brian M. Guter
Michael P. Regan, Jr.
Page 4 of 4
MEDICARE AUTHORIZATION FORM
**ALL SECTIONS REQUIRED * *
oaA
ete. ut Taare use Maun
Ge eu Elgar sels Coy ferrets re ist a
First Name" fiddle Name: |Last Name:
eof Birth (numiddivyyy) Medicare Identification Number
I
Address:
City State: Zip code:
xe (Co) eHe treo)f>yio a7 (iy pygitied
(ities) Re ae ise lee Roa etL Gime en aie Oe ure eit
Select one option: Cl Release all records to date
E1 Release records in timeframe from start date ane va to end date:
include all records
NY residents only:
G exclude information about alcohol and drug abuse, mental health treatment, and HIV
tndicate whether authorization release is for a one-time disclosure, or Identify a future date or event when the authorization will expire.
E1one-tiene disclosure
Select one option: Cexpiration upon specified date Cc).
Dl expiration upon specified event
Rice
i (ened isha tis iai hue aie)
Reniaa RUT Meleleless ou R Do not sign this form unless all applicable tines have been completed. OMB No. 1545-0429
(March 2019)
> Request may be rejected if the form Is incomplete or illegible.
pibeal Rovsnse‘theService
Treasury » For more information about Form 4506, visit www.irs.gov/form4506.
Tip. You may be able to get your tax retum or retum information from other sources. if you had your tax retum completed by a paid preparer, they
should be able to provide you a copy of tha retum. The IRS can provide a Tax Retum Transcript for many returns free of charge. The transcript
provides most of the line entries from the original tax return and usually contains the information that a third party (such as a mortgage
requires. See Form 4506-T, Request for Transcript of Tax Retum, or qi request transcripts by using our automated self-help service
tools. Please visit us at IRS.gov and cli lick on “Get a Tax Transcript..." or ‘call 1-80010-908-9946.
Ya Name shown on tax retum. If a joint return, enter the name shown first. 1b First social security number on tax return,
Individual taxpayer Identification number, or
employer Identification number (see instructions)
‘2a ifa joint retum, enter spouse’s name shown on tax retum. 2b Second social security number or Individual
taxpayer Identification number if joint tax retum
3 Current name, address (including apt., room, or sulte no.), city, state, and ZIP code (see instructions)
4 Previous address shown on the last retum filed if differant from line 3 (see instructions)
5 Ifthe 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.
Caution: If the tax retum is being malted to a third party, ensure that you have filled in lines6 and 7 before signing. Sign and date the form once you
have filled in these lines. Completing these steps helps to protect your privacy. Once the IRS discloses your tax return to the third party listed on line
§, the IRS has no contro! aver what the third party does with the information. If you would like to limit the third party's authority to disclose your return
Information, you can specify this limitation in your written agreement with the third party.
6 Tax retum requested. Form 1040, 1120, 941, etc, and all attachments as originally submitted to the IRS, including Form(s) W-2,
schedules, or amended retums. es of Forms 1040, 1040A, and 1040EZ are generally available for 7 from filing before they are
destroyed by law. Other returns may be available for a longer period of time. Enter only one return number. If you need more than one
type of retum, you must complete another Form 4506.
Note: If the copies must be cerfifled for court or administrative proceedings, check here . a
Yearor period requested. Enter the ending date of the year or period, using the mm/dd/yyyy format. I
elght yearsor periods, you must attach another Form 4506.
you are equesing
move than
Fee. There is a $50 fee for each retum requested. Full payment must be included with your request or it will
be rejected. Make your chock or money order payable to “United States Treasury.” Enter your SSN, ITIN,
or EIN and “Form 4506 request” on your check or money order.
Cost for each retum: . : $ 50.00
b ‘Numberof retums requested ontine 7 : . :
c Total cost, Multiply line 8a byline 8b. . . + $
9 If we cannot find the tax retum, we will refund the fee. Te refund should go to the third party ated on tne, ch eck here . : O
Caution: Do not sign this form unless all applicable tines have been completed.
‘Signature of taxpayer(s). 1 declare that | am either the ayer whose name is shown on line 1a or 2a, or a person auiiorized to obtain the tax retum
requested. If the request applies to a joint retum, at least one spouse must sign. If signed by a corporate officer, 1 percent or more shareholder, er,
member, guardian, tax matters partner, executor, receiver, tor, trustee, or party other than the taxpayer, | certify that | have the authorityto
‘execute Form 4506 on behalf of the taxpayer. Note: This form must be received by IRS within 120 days of the signature date.
D Signatory attests that he/she has read the attestation clause and upon so reading
declares that he/she has the authority to sign the Form 4506. See instructions. Phone number of taxpayer on line
laor2a
Sign » ‘Signature (sea instructions)
|
Date
Here
» ‘Tile (line ta above ls a corporation, partnership,
estate, or rus)
|
» Spouse's signature Date
For Privacy
Act and Paperwork Reduction Act Notice, see page 2. No, 417216 Form 4506 (Rev. 3-2019)
Form 4506 (Rev. 3-2019) Page 2
references aro,to the Internal Revenue Code Chart for all other returns Corporations. Generally, Form 4506 canbe
untessot signed by: (1) an officer having togal authority to bind
tt you fived in. . (2) any person designated by
Future Developments or your business: Mall to: board of directors or other governing body, or (3)
For the latest Information about Form 4506 and its was In: ‘or employeeon jon requestby
go to win. govltomés06. ‘officer
and attested to the secretaryor
information ‘about any recent developments affecting
other officer,
A bona fide. ider of record
Alabama, Alaska, owning 1 percent or more of the
Form 4506, Form 4506-T and Form 4506T-EZ willbe may submit a Form 4506 but must
posted
on that page. Catifomia, Colorado, le documentation to support the requester’s
Delaware, right
to receive:
General Instructions Districtof
Partnerships. Genoraly, Form 4506 can be
Florida, Georgia, Hawall,
‘Caution: Do not sign this form unless all epplicable tdaho, lilinols, signed by any who was a member of the
fines have been complet towa, Kansas, uring any part of the tax pertod
Purpose of form. Use Form 4506 to isiana, Maine, ‘online7.
of your tax return. Youn iso detnao font Tine §) Maryland, Ali others. See section 6103(¢) if the taxpayer has.
a third party to receive dled, is insolvent, .orifa
How long will it take? it trey oko upto 75 Michigan, Minnesota, trustee, guardian, executor, recelver, or
lar days for us to process your request. administrator is acting for the taxpayer.
‘Missouri, Montana, Note: If you are Helrat law, Next
of kin, or
ip. Roa Forin S506-F,- Request for Transcript of Tax Nebraska, Nevada, New
tax account Hampshiro, Naw Jersay, you must de able to establish a material
Roum, toi
ne hon
information, 2 intormatons 1099 information,
verification of nonfiling, and records of account.
‘New Mexico, New York, tntemal pevene Service Interast
In the estate or trust.
Documentation, For entitles ‘than individuals,
Automated transcript request. You can quicl North Dakota, Chio, P.O. Box 9941 you attach the authorization document. For
request transcripts ‘our automated sall-hefp jon, Mail Stop 6734 example, this could be the letter from the princi
Please visit us at IRS.gov and click on Ponnsyivania, Rhodo Ogden, UT 84408 ‘authorizing an employee of the corporation or
“Str ‘or call 1-800-808-994 (stand, the lotters test: ‘an Individualto
South Dakota, act for an estat
Whereto and mail Form 4506
torte adress below forth state you lived in or the
Tennessee, Texas, Utah, ‘Signature by a representative. A representative
state your business was In, when that relum was
Vermont, Virginia,
Washington, West ‘ean sign Form 4806 for a taxpayer only if this
Fed. Thora ao two addoss charts: one Virginia, Wisconsin, authority’ tho
Inalviduel retums (Form 1040 sertes) and one for all @ on Form 2848, line 5a. Form 2848
other retums, }, a foreign showing
the delegation must be attached to Form:
country, American 4506.
Ut you are requesting a retum for more than ane ‘Samoa, Puerto Rico,
year or period and the chart below shows two Guam, Privacy Act and Paperwork Reduction Act
aifferent addresses, send your request to the Commonwealth of the Notice. We ask for the informationon this form to.
address based on the address of your most recent establish ‘to galn access to tho requested
retum, Islands, the U.S. Virgin fetur{s) under the Intemal Revenue Code.Wa need
Islands, or A.P.O. or
Chart for individual returns this information to. Identify the retum{s)and
respond to your request. you request
a copy of a
(Form 1040 series) ‘sections 6103 and 6109 require you to
If you fited an prove tis information, including your SSN or EIN,
Individual return Mall to: Specific Instructions to process request. if you do not provide thi
Information, wa may not ba able to process your
i Une 1b. Enter your employer identification number . Providing
false or fraudutent
Alabama, icky, (EIN) if you ara requesting a copy of a business may subject you to penalties.
Louisiana, Mississippi, 2, enter the first socal security Routine uses of this information
inc!
Tennessee, Texas, a r (SSN) or your individual taxpayer the Department
of Justice for civil
foreign country, American Intemat Revenue Service ‘contiicatian number
1, you are
shown on ths retum, For
requesting Form 1040 that {itigation, and citles, states, the District
of Columbia,
RAIVS Team
iets Ete Com 8 en your So U.S. commonwealths possessionsfor use
Stop 6716 AUSC in administering their tax laws. We may also
‘Commonweaith
of the Austin, TX 73301 Une 3, Enter your curren ityou
use aP.0. disclose this information toto other counties under a
Northem Mariana Islands, box plaase incude ton tis tne 3 tax treaty, to federal and ree
Une 4, Enter the address shown on the last retum federal nontax criminal ‘aw ort fedora taw
AP.O. or F.P.0. address ‘Gifferant from the address entered on lina 3. enforcement
and Intelligence agenclas to combat
Alaska, Arizona, Note: if the addresses on lines 3 and 4 are different
Arkansas, Califor ‘and you have not changed your address with the ‘You are not required to provide the information
all, tdaho, , file Form 6822, Change of Address. Fora requested on a form that ‘Seu‘subject to the
address, file Form 8822-8, Reduction Act untess tho | displays a valid OMB
Michigan, intemal Revenue Service ‘Address or Respansiblo Party — ‘contro! number. Books
or its instructions
or records relating to a form
must be retained as. as their
Nebraska, Nevada, New
RAIVS Team
Stop 37106.
Signature and date. Form 4506 must be signed and ‘contents may become material in the administration
Mexico, North Dakota, eso, dated by the taxpayer listed on line 1a or 2a. Tha
IRS must receive Form 4506 within 120 days of the
of any intemal Revanue 1. Generally, tax retums
and retum Information are Nial, as required
‘South Dakota, Utah,
Gate slanad by the taxpayer or It wil be rejected,
fe tines are completed betore by section 6103.
‘Washington, Wisconsin, sre, imne needed to complete end fe Form 4596
sone will vary dependingon
rN
You must check the box in the estimated aver ‘time is: too ‘about the faw
signature erea to acknowledge or the form, 10 min; Preparing the form, 16 min.;
Delaware, District of ‘and Copying, sssombling, and sending the form
‘Columbia, Flori ‘have the authority to sign and request to the IRS, 20 min.
Georgia, Maina, SEE the information. The form will not be
processed end returned to you if the box is ifyou have comments onceming the accuracy of
intemal Revenue Servica these time estimates or sug: tions for
Massachusetts, RAIVS Team unchecked, Form 4508 simplor, we would be happy to heer from
Hampshire, New Jersey, ‘Stop 6705 S-2
Kansas City, MO Individuals. Coples of jolntly fled tax returms may you. You can write to:
New York, North De furnished to either spouse, Only one signature is intemal Revenue Service
required. Sign Form 4506 oxactly as ‘Tax Forms and Publications Division
appeared of tho original return. i you changed your 1111 Constitution Ave. NW, IR-6525
Island, South Carotina, name, also sign your current name. Washington, DC 20224.
Vermont, Virginia, West
Do not send the form to this address. Instead, see
Where to file on this page.
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Filing # 157928132 E-Filed 09/22/2022 10:41:52 AM IN THE CIRCUIT COURT OF THE FOURTH JUDICIAL CIRCUIT, IN AND FOR DUVAL COUNTY, FLORIDA CASE NO.: 16-2022-CA-004328 DIVISION: CV-G CLARENCE MITCHELL, Plaintiff, vs. VICTORIA NIKALE GREEN, an individual, JULENE TURBEVILLE, an individual, and LINDSAY TYLER DENNIS, an individual, Defendants. DEFENDANT LINDSAY TYLER DENNIS’ REQUEST FOR PRODUCTION TO PLAINTIFF. TO Clarence Mitchell c/o Jessica L. Lanifero, Esquire Morgan & Morgan, P.A. 501 Riverside Avenue, Suite 1200 Jacksonville, FL 32202 Defendant, Lindsay Tyler Dennis, pursuant to Rules 1.280 and 1.350, Florida Rules of Civil Procedure, requests that you produce to Defendant’s undersigned attorneys, at their law offices at 4811 Beach Boulevard, Suite 303, Jacksonville, FL 32207, certain items for inspection and copying. Defendant requests that you produce the following: 1 All of your hospital and medical records (including x-ray, MRI, and CT scan films) and reports regarding the injuries which you claim to have sustained as a result of the accident alleged in your Complaint. All of your hospital, medication, and medical bills regarding the injuries you claim Page 1 of 4 ACCEPTED: DUVAL COUNTY, JODY PHILLIPS, CLERK, 09/22/2022 11:58:22 AM to have sustained as a result of the accident alleged in your Complaint. All other bills or documentary evidence of expenses which you claim to be related to, and caused by, the accident alleged in your Complaint. All medical records, and records of other healthcare providers from doctors, hospitals or anyone else, who has rendered healthcare treatment to you for any injury or medical condition that pre-existed the accident described in the Complaint, but alleged to have been aggravated by the accident. If you have applied for and/or received Medicare benefits, please sign the authorization, original attached, requesting Medicare records. If you have applied for and/or received Medicaid benefits, please sign the authorization, original attached, requesting Medicaid records. All federal income tax returns and all W-2 forms for the time period beginning five years before the accident described in the Complaint and continuing to the present, plus all records of earnings to date for this year. Signed authorizations, originals (two) attached, requesting federal income tax records for the time period beginning five years before the accident. Photographs and negatives purporting to show your injuries, your automobile following the accident alleged in your Complaint, or the scene of the accident alleged in the Complaint. 10. A copy of the enrollment card, membership verification, or other documentation indicating any medical insurance coverage. ll All documents identified in your answers to interrogatories. 12. Photocopies of any driver’s licenses you hold or any other form of photographic identification. 13 All documents evidencing payment of medical bills or lost earnings by collateral sources or evidencing attempts by you to obtain payment from sources other than this Defendant. 14 All estimates and bills for repair of any damage to the vehicles as a result of the accident that is alleged in your Complaint. 15, All recorded, written, or transcribed statements made by witnesses to the accident alleged in your Complaint. Page 2 of 4 16 Signed authorization, original attached, requesting Social Security records. 17 If you have ever served in any branch of the military, please sign the authorization, original attached, requesting military records. 18 Copies of all letters of protection, doctor’s lien, forbearance agreements, or any similar documents you or your attorney has executed in favor of any medical/healthcare provider. 19. All notices of lien that you have received from any entity for any reason. In support of this request for production, Defendant states that the items listed above are in the possession, custody, and control of Plaintiff, that those items constitute or contain matters within the scope of Rule 1.280(b), Florida Rules of Civil Procedure, that Defendant needs those items in the preparation of this case, and that Defendant is unable, without undue hardship, to obtain the substantial equivalent of those items by other means. O'HARA LAW FIRM, Professional Association feo Brian M. Guter Florida Bar No, 113681 Michael P. Regan, Jr. Florida Bar No. 20311 4811 Beach Boulevard, Suite 303 Jacksonville, FL 32207 Telephone (904) 346-3166 Facsimile (904) 346-5445 Service E-Mail: eService @ oharalawfirm.com Attorneys for Lindsay Tyler Dennis Page 3 of 4 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a copy hereof has been furnished to Jessica L. Lanifero, Esquire, Morgan & Morgan, P.A., 501 Riverside Avenue, Suite 1200, Jacksonville, FL 32202, via e-service at jlanifero@forthepeople.com, cfitslaff@ forthepeople.com and mjohnson @ forthepeople.com and to Kendra B. Therrell, Esquire, Law Offices of Kubicki Draper, 76 South Laura Street, Suite 1400, Jacksonville, FL 32202, via e-service at KBT-KD @kubickidraper.com, mpanganiban @ forthepeople.com and rkisling@forthepeople.com and to E. Holland Howanitz, Esquire, Wicker Smith O’Hara Mccoy & Ford P.A., 50 North Laura Street, Suite 2700, Jacksonville, FL 32202, via e-service at JAXcrtpleadings@wickersmith.com on this 22™ day of September, 2022. b20x Brian M. Guter Michael P. Regan, Jr. Page 4 of 4 MEDICARE AUTHORIZATION FORM **ALL SECTIONS REQUIRED * * oaA ete. ut Taare use Maun Ge eu Elgar sels Coy ferrets re ist a First Name" fiddle Name: |Last Name: eof Birth (numiddivyyy) Medicare Identification Number I Address: City State: Zip code: xe (Co) eHe treo)f>yio a7 (iy pygitied (ities) Re ae ise lee Roa etL Gime en aie Oe ure eit Select one option: Cl Release all records to date E1 Release records in timeframe from start date ane va to end date: include all records NY residents only: G exclude information about alcohol and drug abuse, mental health treatment, and HIV tndicate whether authorization release is for a one-time disclosure, or Identify a future date or event when the authorization will expire. E1one-tiene disclosure Select one option: Cexpiration upon specified date Cc). Dl expiration upon specified event Rice i (ened isha tis iai hue aie) Reniaa RUT Meleleless ou R Do not sign this form unless all applicable tines have been completed. OMB No. 1545-0429 (March 2019) > Request may be rejected if the form Is incomplete or illegible. pibeal Rovsnse‘theService Treasury » For more information about Form 4506, visit www.irs.gov/form4506. Tip. You may be able to get your tax retum or retum information from other sources. if you had your tax retum completed by a paid preparer, they should be able to provide you a copy of tha retum. The IRS can provide a Tax Retum Transcript for many returns free of charge. The transcript provides most of the line entries from the original tax return and usually contains the information that a third party (such as a mortgage requires. See Form 4506-T, Request for Transcript of Tax Retum, or qi request transcripts by using our automated self-help service tools. Please visit us at IRS.gov and cli lick on “Get a Tax Transcript..." or ‘call 1-80010-908-9946. Ya Name shown on tax retum. If a joint return, enter the name shown first. 1b First social security number on tax return, Individual taxpayer Identification number, or employer Identification number (see instructions) ‘2a ifa joint retum, enter spouse’s name shown on tax retum. 2b Second social security number or Individual taxpayer Identification number if joint tax retum 3 Current name, address (including apt., room, or sulte no.), city, state, and ZIP code (see instructions) 4 Previous address shown on the last retum filed if differant from line 3 (see instructions) 5 Ifthe 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. Caution: If the tax retum is being malted to a third party, ensure that you have filled in lines6 and 7 before signing. Sign and date the form once you have filled in these lines. Completing these steps helps to protect your privacy. Once the IRS discloses your tax return to the third party listed on line §, the IRS has no contro! aver what the third party does with the information. If you would like to limit the third party's authority to disclose your return Information, you can specify this limitation in your written agreement with the third party. 6 Tax retum requested. Form 1040, 1120, 941, etc, and all attachments as originally submitted to the IRS, including Form(s) W-2, schedules, or amended retums. es of Forms 1040, 1040A, and 1040EZ are generally available for 7 from filing before they are destroyed by law. Other returns may be available for a longer period of time. Enter only one return number. If you need more than one type of retum, you must complete another Form 4506. Note: If the copies must be cerfifled for court or administrative proceedings, check here . a Yearor period requested. Enter the ending date of the year or period, using the mm/dd/yyyy format. I elght yearsor periods, you must attach another Form 4506. you are equesing move than Fee. There is a $50 fee for each retum requested. Full payment must be included with your request or it will be rejected. Make your chock or money order payable to “United States Treasury.” Enter your SSN, ITIN, or EIN and “Form 4506 request” on your check or money order. Cost for each retum: . : $ 50.00 b ‘Numberof retums requested ontine 7 : . : c Total cost, Multiply line 8a byline 8b. . . + $ 9 If we cannot find the tax retum, we will refund the fee. Te refund should go to the third party ated on tne, ch eck here . : O Caution: Do not sign this form unless all applicable tines have been completed. ‘Signature of taxpayer(s). 1 declare that | am either the ayer whose name is shown on line 1a or 2a, or a person auiiorized to obtain the tax retum requested. If the request applies to a joint retum, at least one spouse must sign. If signed by a corporate officer, 1 percent or more shareholder, er, member, guardian, tax matters partner, executor, receiver, tor, trustee, or party other than the taxpayer, | certify that | have the authorityto ‘execute Form 4506 on behalf of the taxpayer. Note: This form must be received by IRS within 120 days of the signature date. D Signatory attests that he/she has read the attestation clause and upon so reading declares that he/she has the authority to sign the Form 4506. See instructions. Phone number of taxpayer on line laor2a Sign » ‘Signature (sea instructions) | Date Here » ‘Tile (line ta above ls a corporation, partnership, estate, or rus) | » Spouse's signature Date For Privacy Act and Paperwork Reduction Act Notice, see page 2. No, 417216 Form 4506 (Rev. 3-2019) Form 4506 (Rev. 3-2019) Page 2 references aro,to the Internal Revenue Code Chart for all other returns Corporations. Generally, Form 4506 canbe untessot signed by: (1) an officer having togal authority to bind tt you fived in. . (2) any person designated by Future Developments or your business: Mall to: board of directors or other governing body, or (3) For the latest Information about Form 4506 and its was In: ‘or employeeon jon requestby go to win. govltomés06. ‘officer and attested to the secretaryor information ‘about any recent developments affecting other officer, A bona fide. ider of record Alabama, Alaska, owning 1 percent or more of the Form 4506, Form 4506-T and Form 4506T-EZ willbe may submit a Form 4506 but must posted on that page. Catifomia, Colorado, le documentation to support the requester’s Delaware, right to receive: General Instructions Districtof Partnerships. Genoraly, Form 4506 can be Florida, Georgia, Hawall, ‘Caution: Do not sign this form unless all epplicable tdaho, lilinols, signed by any who was a member of the fines have been complet towa, Kansas, uring any part of the tax pertod Purpose of form. Use Form 4506 to isiana, Maine, ‘online7. of your tax return. Youn iso detnao font Tine §) Maryland, Ali others. See section 6103(¢) if the taxpayer has. a third party to receive dled, is insolvent, .orifa How long will it take? it trey oko upto 75 Michigan, Minnesota, trustee, guardian, executor, recelver, or lar days for us to process your request. administrator is acting for the taxpayer. ‘Missouri, Montana, Note: If you are Helrat law, Next of kin, or ip. Roa Forin S506-F,- Request for Transcript of Tax Nebraska, Nevada, New tax account Hampshiro, Naw Jersay, you must de able to establish a material Roum, toi ne hon information, 2 intormatons 1099 information, verification of nonfiling, and records of account. ‘New Mexico, New York, tntemal pevene Service Interast In the estate or trust. Documentation, For entitles ‘than individuals, Automated transcript request. You can quicl North Dakota, Chio, P.O. Box 9941 you attach the authorization document. For request transcripts ‘our automated sall-hefp jon, Mail Stop 6734 example, this could be the letter from the princi Please visit us at IRS.gov and click on Ponnsyivania, Rhodo Ogden, UT 84408 ‘authorizing an employee of the corporation or “Str ‘or call 1-800-808-994 (stand, the lotters test: ‘an Individualto South Dakota, act for an estat Whereto and mail Form 4506 torte adress below forth state you lived in or the Tennessee, Texas, Utah, ‘Signature by a representative. A representative state your business was In, when that relum was Vermont, Virginia, Washington, West ‘ean sign Form 4806 for a taxpayer only if this Fed. Thora ao two addoss charts: one Virginia, Wisconsin, authority’ tho Inalviduel retums (Form 1040 sertes) and one for all @ on Form 2848, line 5a. Form 2848 other retums, }, a foreign showing the delegation must be attached to Form: country, American 4506. Ut you are requesting a retum for more than ane ‘Samoa, Puerto Rico, year or period and the chart below shows two Guam, Privacy Act and Paperwork Reduction Act aifferent addresses, send your request to the Commonwealth of the Notice. We ask for the informationon this form to. address based on the address of your most recent establish ‘to galn access to tho requested retum, Islands, the U.S. Virgin fetur{s) under the Intemal Revenue Code.Wa need Islands, or A.P.O. or Chart for individual returns this information to. Identify the retum{s)and respond to your request. you request a copy of a (Form 1040 series) ‘sections 6103 and 6109 require you to If you fited an prove tis information, including your SSN or EIN, Individual return Mall to: Specific Instructions to process request. if you do not provide thi Information, wa may not ba able to process your i Une 1b. Enter your employer identification number . Providing false or fraudutent Alabama, icky, (EIN) if you ara requesting a copy of a business may subject you to penalties. Louisiana, Mississippi, 2, enter the first socal security Routine uses of this information inc! Tennessee, Texas, a r (SSN) or your individual taxpayer the Department of Justice for civil foreign country, American Intemat Revenue Service ‘contiicatian number 1, you are shown on ths retum, For requesting Form 1040 that {itigation, and citles, states, the District of Columbia, RAIVS Team iets Ete Com 8 en your So U.S. commonwealths possessionsfor use Stop 6716 AUSC in administering their tax laws. We may also ‘Commonweaith of the Austin, TX 73301 Une 3, Enter your curren ityou use aP.0. disclose this information toto other counties under a Northem Mariana Islands, box plaase incude ton tis tne 3 tax treaty, to federal and ree Une 4, Enter the address shown on the last retum federal nontax criminal ‘aw ort fedora taw AP.O. or F.P.0. address ‘Gifferant from the address entered on lina 3. enforcement and Intelligence agenclas to combat Alaska, Arizona, Note: if the addresses on lines 3 and 4 are different Arkansas, Califor ‘and you have not changed your address with the ‘You are not required to provide the information all, tdaho, , file Form 6822, Change of Address. Fora requested on a form that ‘Seu‘subject to the address, file Form 8822-8, Reduction Act untess tho | displays a valid OMB Michigan, intemal Revenue Service ‘Address or Respansiblo Party — ‘contro! number. Books or its instructions or records relating to a form must be retained as. as their Nebraska, Nevada, New RAIVS Team Stop 37106. Signature and date. Form 4506 must be signed and ‘contents may become material in the administration Mexico, North Dakota, eso, dated by the taxpayer listed on line 1a or 2a. Tha IRS must receive Form 4506 within 120 days of the of any intemal Revanue 1. Generally, tax retums and retum Information are Nial, as required ‘South Dakota, Utah, Gate slanad by the taxpayer or It wil be rejected, fe tines are completed betore by section 6103. ‘Washington, Wisconsin, sre, imne needed to complete end fe Form 4596 sone will vary dependingon rN You must check the box in the estimated aver ‘time is: too ‘about the faw signature erea to acknowledge or the form, 10 min; Preparing the form, 16 min.; Delaware, District of ‘and Copying, sssombling, and sending the form ‘Columbia, Flori ‘have the authority to sign and request to the IRS, 20 min. Georgia, Maina, SEE the information. The form will not be processed end returned to you if the box is ifyou have comments onceming the accuracy of intemal Revenue Servica these time estimates or sug: tions for Massachusetts, RAIVS Team unchecked, Form 4508 simplor, we would be happy to heer from Hampshire, New Jersey, ‘Stop 6705 S-2 Kansas City, MO Individuals. Coples of jolntly fled tax returms may you. You can write to: New York, North De furnished to either spouse, Only one signature is intemal Revenue Service required. Sign Form 4506 oxactly as ‘Tax Forms and Publications Division appeared of tho original return. i you changed your 1111 Constitution Ave. NW, IR-6525 Island, South Carotina, name, also sign your current name. Washington, DC 20224. Vermont, Virginia, West Do not send the form to this address. Instead, see Where to file on this page.