Preview
Filing # 69303070 E-Filed 03/15/2018 10:46:44 AM
USL-24148MDIS
IN THE CIRCUIT COURT OF THE
TITH JUDICIAL CIRCUIT IN AND FOR
MIAMLDADE COUNTY, FLORIDA
CASE NO.: 17-014926 CA Of (31)
XIOMARA LLERENA AND
ROBERTO LLERENA ,
Plaintiffs,
vs.
QUINTANA FAMILY DAY CARE HOME
D/B/A LEARNING AND GROWING FAMILY
CHILD CARE,
Defendant.
Defendant, QUINTANA FAMILY DAY CARE HOME D/B/A LEARNING AND
GROWING FAMILY CHILD CARE, pursuant to Florida Rule of Civil Procedure 1.350,
requests that Plaintiff, XKOMARA LLERENA, produce and permit Defendant to inspect and
photograph the following:
1. Any and all photographs, films or videotapes in your possession which
depict or purport to depict the scene of the subject incident, any aspect of the subject
incident scene in this case. (Defendant will pay reasonable cost for two (2) reprints.)
2, Any and all photographs, films or videotapes in your possession which
depict or purport to depict any aspect of Plaintiff's injuries herein. (Defendant will pay
reasonable cost of bwe (2) reprints.)3. Any and all medical records which relate to or concern the Plaintiff's injuries
alleged in the Complaint as a result of the subject incident.
4, Any and all medical bills, receipts or invoices which you contend support or
tend to support your damage claims in this case arising from the subject incident.
5, Any and all documents, articles, writings, correspondence, recordings or
memoranda which you contend support or tend to support any allegation set forth in the
Complaint.
6. Any and all written reports from any expert witness or consultant retained by
the Plaintiff.
7. Any and all income Tax returns and W-2 forms from the present time back
five years.
8. Driver's License of the Plaintiff.
9. Social Security card of the Plaintiff.
10, Any and all Marriage Licenses of Plaintiff.
11, Birth Certificate of the Plaintiff.
12, Any and all Ordinance, Regulation, Rule, Statute, custorns and/or practices
and written publications upon which the contentions set forth in your Complaint are based.
13. Any and all Building Standards, local, state or Federal, which the Plaintiff
maintain this Defendant violated at the time of the subject incident.
14. Any and all standards or regulations or recommended practices which the
Plaintiff contends that this Defendant violated with respect to the subject incident.15, Any and all standard which the Plaintiff claims that the Defendant violated or
breached which caused the subject incident.
16. Any and all accident or incident reports generated from any prior accidents
which the Plaintiff was invalved in prior to the subject incident, including any prior slip
and falls, automobile accidents, or other accidents or incidents.
17. Any and all accident or incident reports generated from any subsequent
accidents which the Plaintiff was involved in subsequent to the subject incident, including
any slip and falls, automobile accidents, or other accidents or incidents.
18. Any and ail medical records from any physicians, doctors or hospitals who
treated the Plaintiff as a result of the subject incident.
79. 9 Any and all reports and records of any physician for any treatment to the
Plaintiff for three (3) years prior to the subject incident.
20, Any and all hospital records, nurses’ notes, doctors’ notes, progress notes,
radiology reports, MRI films, x-rays, and MRI reports, and medical bills for any accidents in
which the Plaintiff was involved in prior to the subject incident.
21. Any and all hospital records, nurses’ notes, doctors' notes, progress notes,
radiology reports, MRI films, x-rays, and MRI reports and medical bills for any accidents in
which the Plaintiffs was involved in subsequent to the subject incident.
22, Any and all records supporting a claim for lost wages as a result of the
subject incident.
23, Any and all applicable insurance policies.24, Copies of any “Mary Carter" agreements, loan receipt agreements, settlement
agreements, releases, or covenants not to sue, entered into by you, or on your behalf, with
any other Defendant, person, firm or corporation, whom you contend may have some
liability exposure to the incident of which you complain.
25. Any materials you intend fo use at trial to impeach the parties, their
witnesses or experts, including impeachment material as set forth in and Northup v. Acken,
865 S0.2d 1267 (Fla. 2004).
26. Copies of any and all impeachment materials, including but limited to, prior
depositions, trial transcripts, or other sworn testimony, articles, textbooks, or other writings,
or any other impeachment material not listed above, concerning Defendants’ expert
witnesses that you Intend to use at deposition and/or trial.
27, Copies of any statements of any defendant or employee or agent of any
defendant,
28 Copies of any statements of any witnesses; or the name, address and identity,
including date statement was taken, of any witnesses.
28, A copy of any and all reports or updated reports prepared for the Plaintiff by
Plaintiff's experts, including but not limited to the following:
a Any and all reports (preliminary, final or otherwise), rough
drafts, work sheets and materials in any manner connected with the opinions
or conclusions reached concerning the subject matter of his/her expert
opinion.b. Any and ail materials considered, consulted, and used as a
basis or predicate for opinions and conclusions, including but not limited to,
published articles, data or documents furnished by the party engaging
services,
c. All computations, calculations and formulas considered,
utilized, produced or in any manner connected with opinions or
conclusions.
30, A signed and executed copy of Social Security authorization form SSA-3288,
attached as exhibit “A”,
31, A signed and executed copy of Social Security authorization form SSA-7050-F4,
attached as exhibit “B’.
32, A signed and executed copy of intemal Revenue Service authorization form
4506, attached as exhibit “C”.
33. Acopy of Plaintiff's health insurance card at the time of the incident.
34, Acopy of Plaintiff's current health insurance card.
35. A copy of Plaintiff's automobile insurance card at the time of the incident.
36, Acopy of Plaintiff’s current automobile insurance card.
It is hereby requested that the aforesaid production of copies be made and sent to
the offices of LUKS, SANTANIELLO, PETRILLO & JONES. If plaintiff offers to make such
documents available for inspection only, it is hereby requested that copies be provided to
undersigned counsel and we will reimburse all reasonable or actual charges associated
with said copies.WE HERESY CERTIFY that a true and correct copy of the foregoing has been
furnished via Electronic Mail, to all counsel of record on the attached Service List, this 15th
day of March, 2018.
LUKS, SANTANIELLO,
PETRILLO & JONES
Attorneys for Defendant
150 W, Flagler Street, Suite 2750
Miami, FL 33130
Telephone: (305) 377-8900
Facsimile: (305) 377-8901
By:___./s/ Heather M. Calhoon
DANIEL J. SANTANIELLO
Florida Bar No.: 860948
HEATHER M. CALHOON
Florida Bar No.: 495573
LUKSMIA-Pleadings@LS-Law.comMichael }. Carmona, Esq.
Friedland Law Group
1430 South Dixie Highway
Suite 305
Coral Gables, Fl. 33146
email@friedlandlawgroup.comEXHIBIT
“A”Social Security Administration Form Al
Consent for Release of Information OMB No, 0980-0588
‘You must complete all raquirad fields. We will not honor your request unless all required fields are completed. (‘signifies a
raguirad fleid).
TO: Socal Security Administration
i Fa ss ‘aay Ga SB oe eciat Beauty Namba
{MDDVYYYY)
j authorize the Social Security Administration to release infermation or records about me to:
*NAME OF PERGON OR ORGANIZATION: *ADDRESS OF PERSON OR ORGANIZATION:
“{ want this information released because: _ “cus . eee
We may charge a fee to release information for
"Please release the following Information selected from the let below:
‘You must specify the records you are requesting by checking af least one box. We will not honor a requeat for “any and all
recorda”" ar “my entire file.” Also, we will not disclose records unless you include the applicable date ranges where requested. .
4, [7] Social Security Number
2, (| Current monthly Social Security benefit amount
3. (C] Current monthly Supplemental Security income payment amount
4. (C] My benefit or payment amounts from date _
8. [[] My Medicare entitlement from date ___.
&. (C] Medical records from my olaine fokder(s} from date, to date
H you want us to release @ minor child's medical records, do not not use this form. Instead, contact your local Social
Security office.
7. (] Complete medical records from my claime fotder(s)
8. [7] Other nacord(s) from my file (you must specity the records you are requesting, e.g., doctor report, application,
determination or questionnaire}
lam the individual, to whom the requested Information or record applies, or the parent or legal guardian of a minor, or
the legal guardian of a legally Incompetent adult. i declare under penalty of perjury (26 CFR § 18.41(d)}{2004)) that | have
examined ail the information on this form, and any accompanying statements or forma, and It is true and correct te the
best of my knowledge. | understand that anyone who knowingly or willfully seeks or obtain access to records about
another person under false pretenses is punishable by a fine of up to $6,000, | alse understand that | must pay all
applicable fees for requesting Information for a nen-program-related purpose.
“Date:
Relationship (Hf not the subject of the recerd _ “Daytime Phone: 7
Witnesses must sign this form ONLY if the above signature is by mark 00). If signed by mark (), two witnesses fo the signing
whe know the signes must sign below and provide their full addreeses. Please print the signee's name next to the mark (X) on the
signature ling above.
Signature of witness
2 Signature of witness
Addrese(Number and atrest, City State, and Zip Gode)EXHIBIT
“BY”Forrn SSA-7050-F4 (40-2018) UF Page 2 of 4
REQUEST FOR SOCIAL SECURITY EARNINGS INFORMATION
4, Provide your name aa 8 appears on your most recent Social Security card or the name of the individual whose
eamings you are requeating.
First Name: Middle Initial:
Last Name:
Social Security Number (SSN) - - One SSN per request
Date of Birth: ‘ i Date of Death: ! i
Other Nema(s) Used
(include Maiden Name}
2. What kind of sarnings information do you need? (Choces ORE of the following types of eamings or SSA must return this request.)
(2 Hemized Staternent of Earnings $118 ‘Yoar{e} Requested: te
(includes the names and addresses of employers)
H you check this box, tell us why you need this Information below,
Year(s) Requested: fs
oO Check this box if you want the earings information
CERTIFIEG for an additional $33.00 fas,
["] Certified Yoarly Totels of Eamings 833 ‘Year(a} Requested:
{Boss not include the names and addrevase of empioyara}
Yearly sernings totals are FREE to the public f you de not Years) Requested: to
require cariiication. To abtein FREE yearly totals of samings,
visit our website at wae ane govimyargount
3. if you would like this information sent to someone else, please fill in the information below.
{ authorize the Social Security Administration to release the eamings information to:
Address
City ZIP Code
4. Lam the individual to whom the record pertains (or a person authorized to sign on behalf of that individual). 1
understand that any falee representation to knowingly and willfully obtain information from Social Security records is
year in prison.
Relationship (if applicable, you must attach proof} | Deytine Phone:
th nt poinunnienn mii
Address | State
chy ZIP Code
Witnesses muat aign thie form ONLY iFthe above signature is by marked (0). If elgned by mark (), two witneasea to the signing who
know the signee must sign below and provide thelr full acdraases. Plesae print ihe signes's neme next te the mark (X) on the signature
fins above.
4. Signature of Witness 2. Signature of Witness:
Adidnoas (Number and Shunt, City, Sixda ancl 2° Coote} Addrans (umber and Streat, City, State anef 21 Code)EXHIBIT
“Cc”com SOS Request for Copy of Tax Return
cay 9007) ® De not sign dds form uniese all applicable lines have been completed. OMB No, 1545-0429
& Request amy be rejected if the form is inoompiste or Hegible.
Depart a he Treaairy » For move information about Form 4608, vialt swwurs.gov/formmsi08,
Tis. You may be able to get your tex return or return information from other sources, If you had your fax return completed by a paid preparer, they
should be able te provide you a copy of the return, The IRS can provide « Tax Retin Transeript for many returns free of charge. The tranacrist
provides most of the ling entdes from the original tax retum end usually contains the information that a third party (such ae a mortgage company}
requires. See Porn 4808-7, Request for Transeript of Tax Return, or you can quickly request transoripia by using our automated self-help service
tools. Please visit us at INS.gov and obok on “Get a Tax Transcript...” or call 1-800-008-0846,
Ye Nema shown on fax return. if 8 joint return, enter the name shown first. 4b First social security number on tax return,
individual taxpayer identification number, or
employer identifiegtion number (eee instruction:
‘de Fa joint return, enter apouse’s name shown on tax return. ‘dh Second social eecurlly nember of individual
i taxpayer identification number Hf joint tex return:
~S” Current name, address (including apt., room, or sulle ne}, oly, slate, and ZIP code (eee instructional
‘@ *#revigus address shown on the last return fed ¥ different trom ine 9 (see Inatructiona}
SH the tax retur Is fo be malied fo w Third parly (auch ga @ Mnorigage company), enter the third party's name, address, and telaphone number,
Caution: ff the tax reatuen je being malied to @ third party, enaure that you have filled in lines 6 and 7 before signing. Sign and date the form once you
hewe filed in these Hnea. Completing these stapes helps te protect your privacy. Once the IRS diacloses your tax retumi 0 the third party listed on line
§, the [RS hea ne control over what the thin! party does with the information. if you would [lke te limit the third party's authority to disclose your retum
infermation, you ssn apecify this limitation in your written agraament with the third i party.
@ Tax return requested. Form 1040, 1120, 841, ata. and aff attahments am originally sured to. fe RS, $, including Formig} we,
schedules, of amended returns. Copies of Forms 1040, 104A, and 104082 ara gensrally avaliable 7 years fram fing before “ey are
dastroyad by law, Other retums may be avaliable for a longer period of time. Enter only one arn number. if you need more than one
type of return, you must complete another Form 4808.
Notw: the coples must be certified for sour or aaminiatrative praoeedinge, ¢ 8, check hers. ee ee weg o
7 ‘Yaar or period requested. Enter the ending date of tha year or period, jd, using the mmiddé/yyyy farm: a vox wa requ i re
aight years or periods, you must attach ancther Form 4808,
8 Fae, There is a $50 fas for each retun requested. Pull payment must be included with your request or it will
be rejected, Make your check or money erder paysble to “United States Tressury.” Enter your SSN, ITIN,
or BIN and “Form 4808 request” on your check or monay order,
Gost for each retyen
Number af retume requested on ie 7 «
Total cost, Multiply Ine 8s by Ine Bb
9 ff we cannot find the tax retan, eo wil elu the fee tha ralund whould go to the thd party isa on ina B, chaok here ET .
‘Geutions Oo not sign this forn unless afl applicable lines have bean complete snonsaannnnnonnssnengennosesenusnnsnonesesenenann
sep epee iley ee mabye enon ode pnanpebutionedin tind rate ohare Ladelmece peter enlietebiin dal
ee
a
Bonisian
requeated, ithe mquest applies to a foint retum, af laaet one apouse must sign. 1 signed by a corporate officer, 1 parent ar more ahanshokder, partner,
managing member, guardian, tax matters pertre, executor, receiver, administrator, trustes, or party other then the taxpayer, J oartily that | have the authority to
ensoute Far 4606 on behalf of the taxpayer, Nob: This form must be received by IRS within 120 days of the signature dats,
(O Signatory attests that ha/she has read the attestation clause and upon se reading
deslanse thet hevshe hee the authority te sign the Form 4808, Sas instructions. Phone number of tixpayer on ine
Sign ) aemerecrneaery
Here )
PRET iw TS Sa WW eae, petaaat IG, Manteo HS
» sso
For Srivesy Act and Paperwork Redustion Act Notios, see page 2 Cat, Ries, APR E Form 4508 (ev. 7-207)
Preview
Filing # 69303070 E-Filed 03/15/2018 10:46:44 AM USL-24148MDIS IN THE CIRCUIT COURT OF THE TITH JUDICIAL CIRCUIT IN AND FOR MIAMLDADE COUNTY, FLORIDA CASE NO.: 17-014926 CA Of (31) XIOMARA LLERENA AND ROBERTO LLERENA , Plaintiffs, vs. QUINTANA FAMILY DAY CARE HOME D/B/A LEARNING AND GROWING FAMILY CHILD CARE, Defendant. Defendant, QUINTANA FAMILY DAY CARE HOME D/B/A LEARNING AND GROWING FAMILY CHILD CARE, pursuant to Florida Rule of Civil Procedure 1.350, requests that Plaintiff, XKOMARA LLERENA, produce and permit Defendant to inspect and photograph the following: 1. Any and all photographs, films or videotapes in your possession which depict or purport to depict the scene of the subject incident, any aspect of the subject incident scene in this case. (Defendant will pay reasonable cost for two (2) reprints.) 2, Any and all photographs, films or videotapes in your possession which depict or purport to depict any aspect of Plaintiff's injuries herein. (Defendant will pay reasonable cost of bwe (2) reprints.)3. Any and all medical records which relate to or concern the Plaintiff's injuries alleged in the Complaint as a result of the subject incident. 4, Any and all medical bills, receipts or invoices which you contend support or tend to support your damage claims in this case arising from the subject incident. 5, Any and all documents, articles, writings, correspondence, recordings or memoranda which you contend support or tend to support any allegation set forth in the Complaint. 6. Any and all written reports from any expert witness or consultant retained by the Plaintiff. 7. Any and all income Tax returns and W-2 forms from the present time back five years. 8. Driver's License of the Plaintiff. 9. Social Security card of the Plaintiff. 10, Any and all Marriage Licenses of Plaintiff. 11, Birth Certificate of the Plaintiff. 12, Any and all Ordinance, Regulation, Rule, Statute, custorns and/or practices and written publications upon which the contentions set forth in your Complaint are based. 13. Any and all Building Standards, local, state or Federal, which the Plaintiff maintain this Defendant violated at the time of the subject incident. 14. Any and all standards or regulations or recommended practices which the Plaintiff contends that this Defendant violated with respect to the subject incident.15, Any and all standard which the Plaintiff claims that the Defendant violated or breached which caused the subject incident. 16. Any and all accident or incident reports generated from any prior accidents which the Plaintiff was invalved in prior to the subject incident, including any prior slip and falls, automobile accidents, or other accidents or incidents. 17. Any and all accident or incident reports generated from any subsequent accidents which the Plaintiff was involved in subsequent to the subject incident, including any slip and falls, automobile accidents, or other accidents or incidents. 18. Any and ail medical records from any physicians, doctors or hospitals who treated the Plaintiff as a result of the subject incident. 79. 9 Any and all reports and records of any physician for any treatment to the Plaintiff for three (3) years prior to the subject incident. 20, Any and all hospital records, nurses’ notes, doctors’ notes, progress notes, radiology reports, MRI films, x-rays, and MRI reports, and medical bills for any accidents in which the Plaintiff was involved in prior to the subject incident. 21. Any and all hospital records, nurses’ notes, doctors' notes, progress notes, radiology reports, MRI films, x-rays, and MRI reports and medical bills for any accidents in which the Plaintiffs was involved in subsequent to the subject incident. 22, Any and all records supporting a claim for lost wages as a result of the subject incident. 23, Any and all applicable insurance policies.24, Copies of any “Mary Carter" agreements, loan receipt agreements, settlement agreements, releases, or covenants not to sue, entered into by you, or on your behalf, with any other Defendant, person, firm or corporation, whom you contend may have some liability exposure to the incident of which you complain. 25. Any materials you intend fo use at trial to impeach the parties, their witnesses or experts, including impeachment material as set forth in and Northup v. Acken, 865 S0.2d 1267 (Fla. 2004). 26. Copies of any and all impeachment materials, including but limited to, prior depositions, trial transcripts, or other sworn testimony, articles, textbooks, or other writings, or any other impeachment material not listed above, concerning Defendants’ expert witnesses that you Intend to use at deposition and/or trial. 27, Copies of any statements of any defendant or employee or agent of any defendant, 28 Copies of any statements of any witnesses; or the name, address and identity, including date statement was taken, of any witnesses. 28, A copy of any and all reports or updated reports prepared for the Plaintiff by Plaintiff's experts, including but not limited to the following: a Any and all reports (preliminary, final or otherwise), rough drafts, work sheets and materials in any manner connected with the opinions or conclusions reached concerning the subject matter of his/her expert opinion.b. Any and ail materials considered, consulted, and used as a basis or predicate for opinions and conclusions, including but not limited to, published articles, data or documents furnished by the party engaging services, c. All computations, calculations and formulas considered, utilized, produced or in any manner connected with opinions or conclusions. 30, A signed and executed copy of Social Security authorization form SSA-3288, attached as exhibit “A”, 31, A signed and executed copy of Social Security authorization form SSA-7050-F4, attached as exhibit “B’. 32, A signed and executed copy of intemal Revenue Service authorization form 4506, attached as exhibit “C”. 33. Acopy of Plaintiff's health insurance card at the time of the incident. 34, Acopy of Plaintiff's current health insurance card. 35. A copy of Plaintiff's automobile insurance card at the time of the incident. 36, Acopy of Plaintiff’s current automobile insurance card. It is hereby requested that the aforesaid production of copies be made and sent to the offices of LUKS, SANTANIELLO, PETRILLO & JONES. If plaintiff offers to make such documents available for inspection only, it is hereby requested that copies be provided to undersigned counsel and we will reimburse all reasonable or actual charges associated with said copies.WE HERESY CERTIFY that a true and correct copy of the foregoing has been furnished via Electronic Mail, to all counsel of record on the attached Service List, this 15th day of March, 2018. LUKS, SANTANIELLO, PETRILLO & JONES Attorneys for Defendant 150 W, Flagler Street, Suite 2750 Miami, FL 33130 Telephone: (305) 377-8900 Facsimile: (305) 377-8901 By:___./s/ Heather M. Calhoon DANIEL J. SANTANIELLO Florida Bar No.: 860948 HEATHER M. CALHOON Florida Bar No.: 495573 LUKSMIA-Pleadings@LS-Law.comMichael }. Carmona, Esq. Friedland Law Group 1430 South Dixie Highway Suite 305 Coral Gables, Fl. 33146 email@friedlandlawgroup.comEXHIBIT “A”Social Security Administration Form Al Consent for Release of Information OMB No, 0980-0588 ‘You must complete all raquirad fields. We will not honor your request unless all required fields are completed. (‘signifies a raguirad fleid). TO: Socal Security Administration i Fa ss ‘aay Ga SB oe eciat Beauty Namba {MDDVYYYY) j authorize the Social Security Administration to release infermation or records about me to: *NAME OF PERGON OR ORGANIZATION: *ADDRESS OF PERSON OR ORGANIZATION: “{ want this information released because: _ “cus . eee We may charge a fee to release information for "Please release the following Information selected from the let below: ‘You must specify the records you are requesting by checking af least one box. We will not honor a requeat for “any and all recorda”" ar “my entire file.” Also, we will not disclose records unless you include the applicable date ranges where requested. . 4, [7] Social Security Number 2, (| Current monthly Social Security benefit amount 3. (C] Current monthly Supplemental Security income payment amount 4. (C] My benefit or payment amounts from date _ 8. [[] My Medicare entitlement from date ___. &. (C] Medical records from my olaine fokder(s} from date, to date H you want us to release @ minor child's medical records, do not not use this form. Instead, contact your local Social Security office. 7. (] Complete medical records from my claime fotder(s) 8. [7] Other nacord(s) from my file (you must specity the records you are requesting, e.g., doctor report, application, determination or questionnaire} lam the individual, to whom the requested Information or record applies, or the parent or legal guardian of a minor, or the legal guardian of a legally Incompetent adult. i declare under penalty of perjury (26 CFR § 18.41(d)}{2004)) that | have examined ail the information on this form, and any accompanying statements or forma, and It is true and correct te the best of my knowledge. | understand that anyone who knowingly or willfully seeks or obtain access to records about another person under false pretenses is punishable by a fine of up to $6,000, | alse understand that | must pay all applicable fees for requesting Information for a nen-program-related purpose. “Date: Relationship (Hf not the subject of the recerd _ “Daytime Phone: 7 Witnesses must sign this form ONLY if the above signature is by mark 00). If signed by mark (), two witnesses fo the signing whe know the signes must sign below and provide their full addreeses. Please print the signee's name next to the mark (X) on the signature ling above. Signature of witness 2 Signature of witness Addrese(Number and atrest, City State, and Zip Gode)EXHIBIT “BY”Forrn SSA-7050-F4 (40-2018) UF Page 2 of 4 REQUEST FOR SOCIAL SECURITY EARNINGS INFORMATION 4, Provide your name aa 8 appears on your most recent Social Security card or the name of the individual whose eamings you are requeating. First Name: Middle Initial: Last Name: Social Security Number (SSN) - - One SSN per request Date of Birth: ‘ i Date of Death: ! i Other Nema(s) Used (include Maiden Name} 2. What kind of sarnings information do you need? (Choces ORE of the following types of eamings or SSA must return this request.) (2 Hemized Staternent of Earnings $118 ‘Yoar{e} Requested: te (includes the names and addresses of employers) H you check this box, tell us why you need this Information below, Year(s) Requested: fs oO Check this box if you want the earings information CERTIFIEG for an additional $33.00 fas, ["] Certified Yoarly Totels of Eamings 833 ‘Year(a} Requested: {Boss not include the names and addrevase of empioyara} Yearly sernings totals are FREE to the public f you de not Years) Requested: to require cariiication. To abtein FREE yearly totals of samings, visit our website at wae ane govimyargount 3. if you would like this information sent to someone else, please fill in the information below. { authorize the Social Security Administration to release the eamings information to: Address City ZIP Code 4. Lam the individual to whom the record pertains (or a person authorized to sign on behalf of that individual). 1 understand that any falee representation to knowingly and willfully obtain information from Social Security records is year in prison. Relationship (if applicable, you must attach proof} | Deytine Phone: th nt poinunnienn mii Address | State chy ZIP Code Witnesses muat aign thie form ONLY iFthe above signature is by marked (0). If elgned by mark (), two witneasea to the signing who know the signee must sign below and provide thelr full acdraases. Plesae print ihe signes's neme next te the mark (X) on the signature fins above. 4. Signature of Witness 2. Signature of Witness: Adidnoas (Number and Shunt, City, Sixda ancl 2° Coote} Addrans (umber and Streat, City, State anef 21 Code)EXHIBIT “Cc”com SOS Request for Copy of Tax Return cay 9007) ® De not sign dds form uniese all applicable lines have been completed. OMB No, 1545-0429 & Request amy be rejected if the form is inoompiste or Hegible. Depart a he Treaairy » For move information about Form 4608, vialt swwurs.gov/formmsi08, Tis. You may be able to get your tex return or return information from other sources, If you had your fax return completed by a paid preparer, they should be able te provide you a copy of the return, The IRS can provide « Tax Retin Transeript for many returns free of charge. The tranacrist provides most of the ling entdes from the original tax retum end usually contains the information that a third party (such ae a mortgage company} requires. See Porn 4808-7, Request for Transeript of Tax Return, or you can quickly request transoripia by using our automated self-help service tools. Please visit us at INS.gov and obok on “Get a Tax Transcript...” or call 1-800-008-0846, Ye Nema shown on fax return. if 8 joint return, enter the name shown first. 4b First social security number on tax return, individual taxpayer identification number, or employer identifiegtion number (eee instruction: ‘de Fa joint return, enter apouse’s name shown on tax return. ‘dh Second social eecurlly nember of individual i taxpayer identification number Hf joint tex return: ~S” Current name, address (including apt., room, or sulle ne}, oly, slate, and ZIP code (eee instructional ‘@ *#revigus address shown on the last return fed ¥ different trom ine 9 (see Inatructiona} SH the tax retur Is fo be malied fo w Third parly (auch ga @ Mnorigage company), enter the third party's name, address, and telaphone number, Caution: ff the tax reatuen je being malied to @ third party, enaure that you have filled in lines 6 and 7 before signing. Sign and date the form once you hewe filed in these Hnea. Completing these stapes helps te protect your privacy. Once the IRS diacloses your tax retumi 0 the third party listed on line §, the [RS hea ne control over what the thin! party does with the information. if you would [lke te limit the third party's authority to disclose your retum infermation, you ssn apecify this limitation in your written agraament with the third i party. @ Tax return requested. Form 1040, 1120, 841, ata. and aff attahments am originally sured to. fe RS, $, including Formig} we, schedules, of amended returns. Copies of Forms 1040, 104A, and 104082 ara gensrally avaliable 7 years fram fing before “ey are dastroyad by law, Other retums may be avaliable for a longer period of time. Enter only one arn number. if you need more than one type of return, you must complete another Form 4808. Notw: the coples must be certified for sour or aaminiatrative praoeedinge, ¢ 8, check hers. ee ee weg o 7 ‘Yaar or period requested. Enter the ending date of tha year or period, jd, using the mmiddé/yyyy farm: a vox wa requ i re aight years or periods, you must attach ancther Form 4808, 8 Fae, There is a $50 fas for each retun requested. Pull payment must be included with your request or it will be rejected, Make your check or money erder paysble to “United States Tressury.” Enter your SSN, ITIN, or BIN and “Form 4808 request” on your check or monay order, Gost for each retyen Number af retume requested on ie 7 « Total cost, Multiply Ine 8s by Ine Bb 9 ff we cannot find the tax retan, eo wil elu the fee tha ralund whould go to the thd party isa on ina B, chaok here ET . ‘Geutions Oo not sign this forn unless afl applicable lines have bean complete snonsaannnnnonnssnengennosesenusnnsnonesesenenann sep epee iley ee mabye enon ode pnanpebutionedin tind rate ohare Ladelmece peter enlietebiin dal ee a Bonisian requeated, ithe mquest applies to a foint retum, af laaet one apouse must sign. 1 signed by a corporate officer, 1 parent ar more ahanshokder, partner, managing member, guardian, tax matters pertre, executor, receiver, administrator, trustes, or party other then the taxpayer, J oartily that | have the authority to ensoute Far 4606 on behalf of the taxpayer, Nob: This form must be received by IRS within 120 days of the signature dats, (O Signatory attests that ha/she has read the attestation clause and upon se reading deslanse thet hevshe hee the authority te sign the Form 4808, Sas instructions. Phone number of tixpayer on ine Sign ) aemerecrneaery Here ) PRET iw TS Sa WW eae, petaaat IG, Manteo HS » sso For Srivesy Act and Paperwork Redustion Act Notios, see page 2 Cat, Ries, APR E Form 4508 (ev. 7-207)