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Filing # 164894645 E-Filed 01/17/2023 05:05:20 PM
IN THE CIRCUIT COURT, FIFTH
JUDICIAL CIRCUIT, IN AND FOR,
LAKE COUNTY, FLORIDA
CASE NO.: 2022-CA-002134
MELISSA MAGLIO,
an individual,
Plaintiff,
Vs.
DOLGENCORP, LLC,
a Foreign Limited Liability Company
Defendant.
/
DEFENDANT DOLGENCORP, LLC’S FIRST REQUEST FOR PRODUCTION
TO PLAINTIFF MELISSA MAGLIO
In accordance with Florida Rule of Civil Procedure 1.350, the Defendant,
DOLGENCORP, LLC, by and through its undersigned counsel, hereby requests that Plaintiff,
MELISSA MAGLIO produce the following for inspection and/or copying within thirty (30) days
of service hereof:
1 All medical records, reports, opinions, office records, radiological films and other
written memorandum from doctors, nurses or other medical practitioners in your possession.
2. All medical bills, hospital bills, prescription bills, and/or statements for medical
services, devices and/or medications incurred to date allegedly relating to the subject incident.
3 All documents which show any letters of protection which you have entered into
with any medical providers as a result of the subject incident.
4 Copies of Plaintiff’s federal income tax retums for the five (5) years before the
subject incident through the present, including all attachments (W-2s, W-4s, 1099s, etc.). If not
FILED: LAKE COUNTY, GARY J. COONEY, CLERK, 01/18/2023 08:38:17 AM
in possession, please execute the attached authorization for the years stated and return the
original so that said returns can be obtained from the Internal Revenue Service.
5 Any and all records, written memoranda, letters, correspondence, or statements
which reflect or support any amount of lost wages, time lost from work, and/or or lost earning
capacity due to injuries allegedly suffered as a result of the subject incident.
6 Copies of any claims which may have been made by the Plaintiff with the Florida
Department of Unemployment Compensation or similar department of other states, for benefits
paid or payable to the Plaintiff for the injuries and/or damages allegedly suffered as a result of
the subject incident.
7 Any documents which constitute, evidence, or reflect any special damages
Plaintiff alleges to have suffered as a result of the subject incident for which Plaintiff is seeking
compensation, other than medical bills and lost wages.
8 Photographs of the area in which Plaintiff claims the subject incident occurred.
9 Photographs of the Plaintiff following the subject incident purporting to show or
depict injuries allegedly sustained as a result of the subject incident.
10. All statements concerning this action, or the subject matter of this action made by
the Plaintiff.
11. All statements concerning this action or the subject matter of this action made by
the Defendants and/or the Defendants’ agents, servants, and employees.
12. All statements concerning this action or the subject matter of this action made by
any witness.
13. Plaintiff's driver’s license or state issued photo identification card.
14. Plaintiff's insurance card(s) for any health insurance in effect at the time of the
alleged accident and since that time.
15. Any statements from providers of collateral source payments which assert a right
to subrogation or reimbursement pursuant to Florida Statutes.
16. If applicable, a copy of any Medicare card that has been issued to you; any
communication(s) from Medicare that you are entitled to or will become eligible for Medicare
benefits; any and all claim(s) and/or application(s).
17. All reports received from any experts the Plaintiff intends to call at the time of
trial and copies of all documents the experts have reviewed in preparation for rendering any
opinions in this case.
CERTIFICATE OF SERVICE
I HEREBY CERTIFY that a copy of the foregoing has been furnished via the Florida
Courts E-Filing Portal System to Lisa M. Nommensen, Esquire, Law Office of Nooney,
Roberts, Hewett & Nowicki, 1680 Emerson Street, Jacksonville, FL 32207, lisa@nrhnlaw.com,
and smeneil@nrhnlaw.com, Attorney for Plaintiff, on this 17" day of January, 2022.
ST. DENIS & DAVEY, P.A.
Florida Bar Number 016121
kacie@sdtriallaw.com
1300 Riverplace Boulevard, Suite 401
Jacksonville, Florida 32207
(904) 396-1996 — Telephone
(904) 396-1991 — Facsimile
Attorneys for Dolgencorp, LLC
rom 4506 Request for Copy of Tax Return
(Novmeber 2021) > Do not sign this form unless all applicable lines have been completed. OMB No. 1545-0429
» Request may be rejected if the form is incomplete or illegible.
Department of the Treasury > For more information about Form 4506, visit www.irs.gov/form4506.
Internal Revenue Service
Tip: Get faster service: Online at www.irs.gov, Get Your Tax Record (Get Transcript) or by calling 1-800-908-9946 for specialized assistance. We
have teams available to assist. Note: Taxpayers may register to use to view, print, or download the following transcript types: Tax
Retum Transcript (shows most line items including Adjusted Gross Income (AGI) from your original Form 1040-series tax retum as filed, along with
any forms and schedules), Tax Account Transcript (shows basic data such as return type, marital status, AGI, taxable income and all payment types),
Record of Account Transcript (combines the tax retum and tax account transcripts into one complete transcript), Wage and Income Transcript
(shows data from information returns we receive such as Forms W-2, 1099, 1098 and Form 5498), and Verification of Non-filing Letter (provides
proof that the IRS has no record of a filed Form 1040-series tax return for the year you request).
ta Name shown on tax return. 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 return, enter spouse’s name shown on tax return. 2b Second social security number o1 dividual
taxpayer identification number if joint tax return
3 Current name, address (including apt., room, or suite no.), city, state, and ZIP code (see instructions)
4 Previous address shown on the last return filed if different from line 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.
St. Denis & Davey, P.A., 1300 Riverplace Blvd., Suite 401, Jacksonville, FL 32207 (904) 396-1996
Caution: If the tax retum is being sent to the third party, ensure that lines 5 through 7 are completed before signing. (See instructions).
6 ‘Tax return requested. Form 1040, 1120, 941, etc. and all attachments as originally submitted to the IRS, including Form(s) W-2,
schedules, or amended returns. Copies of Forms 1040, 1040A, and 1040EZ are generally available for 7 years 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 return, you must complete another Form 4506. >
Note: [f the copies must be certified for court or administrative proceedings, check here oO
Year or period requested. Enter the ending date of the tax year or period using the mmvVdd/yyyy format eee instucton@)
12_/_31/ 2016 12 / 31 /2017 12_/ 31/2018 12_/_31_/2019_
12 7 31 /2020 12_/_31/ 2021 J / / /
Fee. There is a $43 fee for each return requested. Full payment must be included with your request or it will
be rejected. Make your check 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 return . . . $ 43.00
b Number of returns requested on line 7 : .
c Total cost. Multiply line 8a by line 8b : : : $
9 If we cannot find the tax retum, we will refund the fee. If the ratund thould gooto tre third party Tsted on line 5, check here . Xi
Caution: Do not sign this form unless all applicable lines have been completed.
Signature of taxpayer(s). | declare that | am either the taxpayer whose name is shown on line fa 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, | certify that | 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,
[X] 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
taor2a
|
) ‘Signature (see Instructions) Date
Sign
Here ) Print/Type name Title (Fine Ta above is a corporation, partnership, estate, or trust)
) ‘Spouse's signature Date
b Prinviype name
For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 41721E Form 4506 (Rev. 11-2021)
Form 4506 (Rev. 11-2021) Page 2
‘Section references are to the Internal Revenue Code Individuals. Copies of jointly filed tax retums may
unless otherwise noted. Chart for all other returns be furnished to either spouse. Only one signature Is
required. Sign Form 4506 exactly as your name
For returns not in appeared on the original return. if you changed your
Future Developments Form 1040 series, Mail to: name, also sign your current name.
For the latest information about Form 4506 and its if the address on Corporations. Generally, Form 4506 can be
Instructions, go to www.lrs. gov/form4506. the return was in: signed by: (1) an officer having legal authorityto bind
the corporation, (2) any person designated by the
General Instructions Connecticut, Delaware, board of directors or other governing body, or (3)
Caution: Do not sign this form unless all applicable District of Columbia, any officer or employee on written request by any
lines, including lines 5 through 7, have been Georgia, Illinois, Indiana, principal officer and attested to by the secretary or
completed. Kentucky, Maine, other officer. A bona fide shareholder of record
Designated Recipient Notification. Internal
Maryland, owning 1 percent or more of the outstanding stock
Massachusetts, Intemal Revenue Service of the corporation may submita Form 4506 but must
Revenue Code, Section 6103(¢), limits disclosure Michigan, New RAIVS Team provide documentation to support the requester's
and use of return information received pursuant to Hampshire, New Jersey, Stop 6705 S-2 tight to receive the information,
the taxpayer’s consent and holds the recipient New York, North Kansas City, MO Partnerships. Generally, Form 4506 can be
subject to penalties for any unauthorized access, Carolina, Ohio, signed by any person who was a member of the
other use, or redisclosure without the taxpayer's. Pennsylvania, Rhode partnership during any part of the tax period
express permission or request. Island, South Carolina, requested on line 7.
‘Taxpayer Notification. Internal Revenue Code, ‘Tennessee, Vermont,
All others. See section 6103(e) ifthe taxpayer has
‘Section 6103(0), limits disclosure and use of return Virginia, West Virginia, died, is insolvent, is a dissolved corporation, or if a
information provided pursuant to your consent and Wisconsin
holds the recipient subject to penalties, brought by trustee, guardian, executor, receiver, or
private right of action, for any unauthorized access, administrator is acting for the taxpayer.
Alabama, Alaska,
other use, or redisclosure without your express Arizona, Arkansas, Note: If you are Heir at law, Next of kin, or
permission or request. California, Colorado, Beneficiary you must be able to establish a material
Purpose of form. Use Form 4506 to request a copy Florida, Hawaii, Idaho, interest in the estate or trust.
of your tax return. You can also designate (on line 8) lowa, Kansas, Louisiana, Documentation. For entities other than individuals,
a third party to receive the tax return, Minnesota, Mississippi, you must attach the authorization document. For
How long will it take? It may take up to 76 Missouri, Montana, ‘example, this could be the letter from the pri
calendar days for us to process your request. Nebraska, Nevada, New officer authorizing an employee of the corporation or
Mexico, North Dakota, Internal Revenue Service the letters testamentary authorizing an individual to
Where to file. Attach payment and mail Form 4506 ‘Oklahoma, Oregon, RAIVS Team act for an estate.
to the acidress below for the state you lived in, or the South Dakota, Texas, P.O. Box 9941 Signature by a representative. A representative
state your business was in, when that return was Utah, Washington, Mail Stop 6734 can sign Form 4506 for a taxpayer only if this
filed. There are two address charts: one for Wyorning, a foreign ‘Ogden, UT 84409 authority has been specifically delegated to the
individual returns (Form 1040 series) and one for all country, American representative on Form 2848, line 5a. Form 2848
other returns. ‘Samoa, Puerto Rico, showing the delegation must be attached to Form
If you are requesting a return for more than one Guam, the
year or period and the chart below shows two ‘Commonwealth of the
different addresses, send your request based on the Northern Mariana Privacy Act and Paperwork Reduction Act
address of your most recent return. Islands, the U.S. Virgin
Islands, or A.P.O. or Notice. We ask for the Information on this form to
Chart for individual returns F.P.0. address establish your right to gain access to the requested
return(s) under the Internal Revenue Code. We need
(Form 1040 series) this information to properly identify the return(s) and
Ifyou filed an Specific Instructions respond to your request. If you request a copy ofa
tax return, sections 6103 and 6109 require you to
individual return Mail to: Line 1b. Enter the social security number (SSN) or provide this information, including your SSN or EIN,
and lived in: individual taxpayer identification number (ITIN) for to process your request. If you do not provide this
the individual listed on line 1a, or enter the employer information, we may not be able to process your
Florida, Louisiana, identification number (EIN) for the business listed on request. Providing false or fraudulent information
Mississippl, Texas, a line 1a, For example, if you are requesting Form may subject you to penalties.
foreign country, American Internal Revenue Service 1040 that includes Schedule C (Form 1040), enter Routine uses of this information include giving it to
Samoa, Puerto Rico, feat your SSN. the Department of Justice for civil and criminal
Guam, the Stop 6716 ’AUSC Line 8, Enter your current address. if you use a P.O. litigation, and cities, states, the District of Columbia,
‘Commonwealth of the Austin, TX 73301 box, please include it on this line 3. an commonwealths and possessions for use
Northern Mariana Islands, in administering their tax laws. We may also
the |.S. Virgin Islands, or Line 4, Enter the address shown on the last return disclose this information to other countries under a
oF F.P.O, address file different from the address entered on line 3.
tax treaty, to federal and state agencies to enforce
Note. If the addresses on lines 3 and 4 are different federal nontax criminal laws, or to federal law
and you have not changed your address with the enforcement and intelligence agencies to combat
Alabama, Arkansas, IRS, file Form 8822, Change of Address, or Form terrorism.
Delaware, Georgia, 8822-B,Change of Address or Responsible Party —
illinois, Indiana, lowa, Business, with Form 4506. You are not required to provide the information
Kentucky, Maine, Line 7. Enter the end date of the tax year or period requested on a form that is subject to the Paperwork.
Massachusetts, Internal Revenue Service Reduction Act unless the form displays a valid OMB
Minnesota, Missouri, RAIVS Team requested in mm/dd/yy format. This may be a control number. Books or records relating to a form
New Hampshire, New ‘Stop 6705 S-2 calendar year, fiscal year or quarter. Enter each or its instructions must be retained as long as their
Jersey, New York, North Kansas City, MO 64999 quarter réquested for quarterly returns. Example: contents may become material in the administration
Carolina, Oklahoma, Enter 12/31/2018 for a calendar year 2018 Form of any Internal Revenue law. Generally, tax returns.
South Carolina, 1040 return, or 03/31/2017 fora first quarter Form and retum information are confidential, as required
‘Tennessee, Vermont, 941 return. by section 6103.
Virginia, Wisconsin Signature and date. Form 4506 must be signed and The time needed to complete and file Form 4506
dated by the taxpayer listed on line 1a or 2a. The will vary depending on individual circumstances. The
Alaska, Arizona, IRS must receive Form 4506 within 120 days of the estimated average time is: Learning about the law
California, Colorado, date signed by the taxpayer orit will be rejected. or the form, 10 min.; Preparing the form, 16 min.;
Connecticut, District of Ensure that all applicable lines, including lines 5 and Copying, assembling, and sending the form
Columbia, Hawaii, Idaho, through 7, are completed before signing. to the IRS, 20 min.
Kansas, Maryland, Internal Revenue Service Ifyou have comments conceming the accuracy of
IN
Michigan, Montana, RAIVS Team You must check the box in the
Nebraska, Nevada, New P.O. Box 9941 signature area to acknowledge you these time estimates or suggestions for making
Mexico, North Dakota, Mail Stop 6734 have the authority to sign and request Form 4506 simpler, we would be happy to hear from
Ohio, Oregon, Ogden, UT 84409 Cie the information. The form will not be
you. You can write to:
Pennsylvania, Rhode processed and retumed to you if the box is Internal Revenue Service
Island, South Dakota, unchecked. ‘Tax Forms and Publications Division
Utah, Washington, West 4111 Constitution Ave. NW, IR-6526
Virginia, Wyoming Washington, DC 20224,
Do not send the form to this address. Instead, see
Where to file on this page.
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Filing # 164894645 E-Filed 01/17/2023 05:05:20 PM IN THE CIRCUIT COURT, FIFTH JUDICIAL CIRCUIT, IN AND FOR, LAKE COUNTY, FLORIDA CASE NO.: 2022-CA-002134 MELISSA MAGLIO, an individual, Plaintiff, Vs. DOLGENCORP, LLC, a Foreign Limited Liability Company Defendant. / DEFENDANT DOLGENCORP, LLC’S FIRST REQUEST FOR PRODUCTION TO PLAINTIFF MELISSA MAGLIO In accordance with Florida Rule of Civil Procedure 1.350, the Defendant, DOLGENCORP, LLC, by and through its undersigned counsel, hereby requests that Plaintiff, MELISSA MAGLIO produce the following for inspection and/or copying within thirty (30) days of service hereof: 1 All medical records, reports, opinions, office records, radiological films and other written memorandum from doctors, nurses or other medical practitioners in your possession. 2. All medical bills, hospital bills, prescription bills, and/or statements for medical services, devices and/or medications incurred to date allegedly relating to the subject incident. 3 All documents which show any letters of protection which you have entered into with any medical providers as a result of the subject incident. 4 Copies of Plaintiff’s federal income tax retums for the five (5) years before the subject incident through the present, including all attachments (W-2s, W-4s, 1099s, etc.). If not FILED: LAKE COUNTY, GARY J. COONEY, CLERK, 01/18/2023 08:38:17 AM in possession, please execute the attached authorization for the years stated and return the original so that said returns can be obtained from the Internal Revenue Service. 5 Any and all records, written memoranda, letters, correspondence, or statements which reflect or support any amount of lost wages, time lost from work, and/or or lost earning capacity due to injuries allegedly suffered as a result of the subject incident. 6 Copies of any claims which may have been made by the Plaintiff with the Florida Department of Unemployment Compensation or similar department of other states, for benefits paid or payable to the Plaintiff for the injuries and/or damages allegedly suffered as a result of the subject incident. 7 Any documents which constitute, evidence, or reflect any special damages Plaintiff alleges to have suffered as a result of the subject incident for which Plaintiff is seeking compensation, other than medical bills and lost wages. 8 Photographs of the area in which Plaintiff claims the subject incident occurred. 9 Photographs of the Plaintiff following the subject incident purporting to show or depict injuries allegedly sustained as a result of the subject incident. 10. All statements concerning this action, or the subject matter of this action made by the Plaintiff. 11. All statements concerning this action or the subject matter of this action made by the Defendants and/or the Defendants’ agents, servants, and employees. 12. All statements concerning this action or the subject matter of this action made by any witness. 13. Plaintiff's driver’s license or state issued photo identification card. 14. Plaintiff's insurance card(s) for any health insurance in effect at the time of the alleged accident and since that time. 15. Any statements from providers of collateral source payments which assert a right to subrogation or reimbursement pursuant to Florida Statutes. 16. If applicable, a copy of any Medicare card that has been issued to you; any communication(s) from Medicare that you are entitled to or will become eligible for Medicare benefits; any and all claim(s) and/or application(s). 17. All reports received from any experts the Plaintiff intends to call at the time of trial and copies of all documents the experts have reviewed in preparation for rendering any opinions in this case. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a copy of the foregoing has been furnished via the Florida Courts E-Filing Portal System to Lisa M. Nommensen, Esquire, Law Office of Nooney, Roberts, Hewett & Nowicki, 1680 Emerson Street, Jacksonville, FL 32207, lisa@nrhnlaw.com, and smeneil@nrhnlaw.com, Attorney for Plaintiff, on this 17" day of January, 2022. ST. DENIS & DAVEY, P.A. Florida Bar Number 016121 kacie@sdtriallaw.com 1300 Riverplace Boulevard, Suite 401 Jacksonville, Florida 32207 (904) 396-1996 — Telephone (904) 396-1991 — Facsimile Attorneys for Dolgencorp, LLC rom 4506 Request for Copy of Tax Return (Novmeber 2021) > Do not sign this form unless all applicable lines have been completed. OMB No. 1545-0429 » Request may be rejected if the form is incomplete or illegible. Department of the Treasury > For more information about Form 4506, visit www.irs.gov/form4506. Internal Revenue Service Tip: Get faster service: Online at www.irs.gov, Get Your Tax Record (Get Transcript) or by calling 1-800-908-9946 for specialized assistance. We have teams available to assist. Note: Taxpayers may register to use to view, print, or download the following transcript types: Tax Retum Transcript (shows most line items including Adjusted Gross Income (AGI) from your original Form 1040-series tax retum as filed, along with any forms and schedules), Tax Account Transcript (shows basic data such as return type, marital status, AGI, taxable income and all payment types), Record of Account Transcript (combines the tax retum and tax account transcripts into one complete transcript), Wage and Income Transcript (shows data from information returns we receive such as Forms W-2, 1099, 1098 and Form 5498), and Verification of Non-filing Letter (provides proof that the IRS has no record of a filed Form 1040-series tax return for the year you request). ta Name shown on tax return. 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 return, enter spouse’s name shown on tax return. 2b Second social security number o1 dividual taxpayer identification number if joint tax return 3 Current name, address (including apt., room, or suite no.), city, state, and ZIP code (see instructions) 4 Previous address shown on the last return filed if different from line 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. St. Denis & Davey, P.A., 1300 Riverplace Blvd., Suite 401, Jacksonville, FL 32207 (904) 396-1996 Caution: If the tax retum is being sent to the third party, ensure that lines 5 through 7 are completed before signing. (See instructions). 6 ‘Tax return requested. Form 1040, 1120, 941, etc. and all attachments as originally submitted to the IRS, including Form(s) W-2, schedules, or amended returns. Copies of Forms 1040, 1040A, and 1040EZ are generally available for 7 years 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 return, you must complete another Form 4506. > Note: [f the copies must be certified for court or administrative proceedings, check here oO Year or period requested. Enter the ending date of the tax year or period using the mmvVdd/yyyy format eee instucton@) 12_/_31/ 2016 12 / 31 /2017 12_/ 31/2018 12_/_31_/2019_ 12 7 31 /2020 12_/_31/ 2021 J / / / Fee. There is a $43 fee for each return requested. Full payment must be included with your request or it will be rejected. Make your check 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 return . . . $ 43.00 b Number of returns requested on line 7 : . c Total cost. Multiply line 8a by line 8b : : : $ 9 If we cannot find the tax retum, we will refund the fee. If the ratund thould gooto tre third party Tsted on line 5, check here . Xi Caution: Do not sign this form unless all applicable lines have been completed. Signature of taxpayer(s). | declare that | am either the taxpayer whose name is shown on line fa 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, | certify that | 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, [X] 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 taor2a | ) ‘Signature (see Instructions) Date Sign Here ) Print/Type name Title (Fine Ta above is a corporation, partnership, estate, or trust) ) ‘Spouse's signature Date b Prinviype name For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 41721E Form 4506 (Rev. 11-2021) Form 4506 (Rev. 11-2021) Page 2 ‘Section references are to the Internal Revenue Code Individuals. Copies of jointly filed tax retums may unless otherwise noted. Chart for all other returns be furnished to either spouse. Only one signature Is required. Sign Form 4506 exactly as your name For returns not in appeared on the original return. if you changed your Future Developments Form 1040 series, Mail to: name, also sign your current name. For the latest information about Form 4506 and its if the address on Corporations. Generally, Form 4506 can be Instructions, go to www.lrs. gov/form4506. the return was in: signed by: (1) an officer having legal authorityto bind the corporation, (2) any person designated by the General Instructions Connecticut, Delaware, board of directors or other governing body, or (3) Caution: Do not sign this form unless all applicable District of Columbia, any officer or employee on written request by any lines, including lines 5 through 7, have been Georgia, Illinois, Indiana, principal officer and attested to by the secretary or completed. Kentucky, Maine, other officer. A bona fide shareholder of record Designated Recipient Notification. Internal Maryland, owning 1 percent or more of the outstanding stock Massachusetts, Intemal Revenue Service of the corporation may submita Form 4506 but must Revenue Code, Section 6103(¢), limits disclosure Michigan, New RAIVS Team provide documentation to support the requester's and use of return information received pursuant to Hampshire, New Jersey, Stop 6705 S-2 tight to receive the information, the taxpayer’s consent and holds the recipient New York, North Kansas City, MO Partnerships. Generally, Form 4506 can be subject to penalties for any unauthorized access, Carolina, Ohio, signed by any person who was a member of the other use, or redisclosure without the taxpayer's. Pennsylvania, Rhode partnership during any part of the tax period express permission or request. Island, South Carolina, requested on line 7. ‘Taxpayer Notification. Internal Revenue Code, ‘Tennessee, Vermont, All others. See section 6103(e) ifthe taxpayer has ‘Section 6103(0), limits disclosure and use of return Virginia, West Virginia, died, is insolvent, is a dissolved corporation, or if a information provided pursuant to your consent and Wisconsin holds the recipient subject to penalties, brought by trustee, guardian, executor, receiver, or private right of action, for any unauthorized access, administrator is acting for the taxpayer. Alabama, Alaska, other use, or redisclosure without your express Arizona, Arkansas, Note: If you are Heir at law, Next of kin, or permission or request. California, Colorado, Beneficiary you must be able to establish a material Purpose of form. Use Form 4506 to request a copy Florida, Hawaii, Idaho, interest in the estate or trust. of your tax return. You can also designate (on line 8) lowa, Kansas, Louisiana, Documentation. For entities other than individuals, a third party to receive the tax return, Minnesota, Mississippi, you must attach the authorization document. For How long will it take? It may take up to 76 Missouri, Montana, ‘example, this could be the letter from the pri calendar days for us to process your request. Nebraska, Nevada, New officer authorizing an employee of the corporation or Mexico, North Dakota, Internal Revenue Service the letters testamentary authorizing an individual to Where to file. Attach payment and mail Form 4506 ‘Oklahoma, Oregon, RAIVS Team act for an estate. to the acidress below for the state you lived in, or the South Dakota, Texas, P.O. Box 9941 Signature by a representative. A representative state your business was in, when that return was Utah, Washington, Mail Stop 6734 can sign Form 4506 for a taxpayer only if this filed. There are two address charts: one for Wyorning, a foreign ‘Ogden, UT 84409 authority has been specifically delegated to the individual returns (Form 1040 series) and one for all country, American representative on Form 2848, line 5a. Form 2848 other returns. ‘Samoa, Puerto Rico, showing the delegation must be attached to Form If you are requesting a return for more than one Guam, the year or period and the chart below shows two ‘Commonwealth of the different addresses, send your request based on the Northern Mariana Privacy Act and Paperwork Reduction Act address of your most recent return. Islands, the U.S. Virgin Islands, or A.P.O. or Notice. We ask for the Information on this form to Chart for individual returns F.P.0. address establish your right to gain access to the requested return(s) under the Internal Revenue Code. We need (Form 1040 series) this information to properly identify the return(s) and Ifyou filed an Specific Instructions respond to your request. If you request a copy ofa tax return, sections 6103 and 6109 require you to individual return Mail to: Line 1b. Enter the social security number (SSN) or provide this information, including your SSN or EIN, and lived in: individual taxpayer identification number (ITIN) for to process your request. If you do not provide this the individual listed on line 1a, or enter the employer information, we may not be able to process your Florida, Louisiana, identification number (EIN) for the business listed on request. Providing false or fraudulent information Mississippl, Texas, a line 1a, For example, if you are requesting Form may subject you to penalties. foreign country, American Internal Revenue Service 1040 that includes Schedule C (Form 1040), enter Routine uses of this information include giving it to Samoa, Puerto Rico, feat your SSN. the Department of Justice for civil and criminal Guam, the Stop 6716 ’AUSC Line 8, Enter your current address. if you use a P.O. litigation, and cities, states, the District of Columbia, ‘Commonwealth of the Austin, TX 73301 box, please include it on this line 3. an commonwealths and possessions for use Northern Mariana Islands, in administering their tax laws. We may also the |.S. Virgin Islands, or Line 4, Enter the address shown on the last return disclose this information to other countries under a oF F.P.O, address file different from the address entered on line 3. tax treaty, to federal and state agencies to enforce Note. If the addresses on lines 3 and 4 are different federal nontax criminal laws, or to federal law and you have not changed your address with the enforcement and intelligence agencies to combat Alabama, Arkansas, IRS, file Form 8822, Change of Address, or Form terrorism. Delaware, Georgia, 8822-B,Change of Address or Responsible Party — illinois, Indiana, lowa, Business, with Form 4506. You are not required to provide the information Kentucky, Maine, Line 7. Enter the end date of the tax year or period requested on a form that is subject to the Paperwork. Massachusetts, Internal Revenue Service Reduction Act unless the form displays a valid OMB Minnesota, Missouri, RAIVS Team requested in mm/dd/yy format. This may be a control number. Books or records relating to a form New Hampshire, New ‘Stop 6705 S-2 calendar year, fiscal year or quarter. Enter each or its instructions must be retained as long as their Jersey, New York, North Kansas City, MO 64999 quarter réquested for quarterly returns. Example: contents may become material in the administration Carolina, Oklahoma, Enter 12/31/2018 for a calendar year 2018 Form of any Internal Revenue law. Generally, tax returns. South Carolina, 1040 return, or 03/31/2017 fora first quarter Form and retum information are confidential, as required ‘Tennessee, Vermont, 941 return. by section 6103. Virginia, Wisconsin Signature and date. Form 4506 must be signed and The time needed to complete and file Form 4506 dated by the taxpayer listed on line 1a or 2a. The will vary depending on individual circumstances. The Alaska, Arizona, IRS must receive Form 4506 within 120 days of the estimated average time is: Learning about the law California, Colorado, date signed by the taxpayer orit will be rejected. or the form, 10 min.; Preparing the form, 16 min.; Connecticut, District of Ensure that all applicable lines, including lines 5 and Copying, assembling, and sending the form Columbia, Hawaii, Idaho, through 7, are completed before signing. to the IRS, 20 min. Kansas, Maryland, Internal Revenue Service Ifyou have comments conceming the accuracy of IN Michigan, Montana, RAIVS Team You must check the box in the Nebraska, Nevada, New P.O. Box 9941 signature area to acknowledge you these time estimates or suggestions for making Mexico, North Dakota, Mail Stop 6734 have the authority to sign and request Form 4506 simpler, we would be happy to hear from Ohio, Oregon, Ogden, UT 84409 Cie the information. The form will not be you. You can write to: Pennsylvania, Rhode processed and retumed to you if the box is Internal Revenue Service Island, South Dakota, unchecked. ‘Tax Forms and Publications Division Utah, Washington, West 4111 Constitution Ave. NW, IR-6526 Virginia, Wyoming Washington, DC 20224, Do not send the form to this address. Instead, see Where to file on this page.