Preview
Filing # 113712292 E-Filed 09/21/2020 04:44:52 PM
IN THE CIRCUIT COURT OF THE
FIFTEENTH JUDICIAL CIRCUIT IN AND
FOR PALM BEACH COUNTY, FLORIDA
CIRCUIT CIVIL DIVISION
CASE NO.: 50-2020-CA-007743 (AN)
JUSTINO VEGA PENA and JUSTIN
WILLIE VEGA,
Plaintiff,
v.
SONY JOSEPH and HL UNIVERSAL, INC.,
a Florida Profit Corporation,
Defendants.
/
DEFENDANTS’ FIRST REQUEST FOR PRODUCTION TO
PLAINTIFF, JUSTINO VEGA PENA
COMES NOW Defendants, by and through their undersigned counsel, and requests that
Plaintiff, JUSTINO VEGA PENA produce the following for inspection and/or copying at the offices
of Lewis Brisbois Bisgaard & Smith LLP, Attorneys for Defendants, 110 SE 6" Street, Suite 2600,
Fort Lauderdale, Florida 33301 within thirty (30) days from the date hereof pursuant to Rule 1.350,
Fla.R.Civ.P.
1. Copies of Income Tax Returns, including all schedules, attachments and W2 forms, or
a properly executed authorization for obtaining a true copy of Federal Income Tax Retums for the
three year period prior to the date of accident to date.
2. A record of earings for the current year to date.
3. Any and all medical records for treatment resulting from the lawsuit incident
including, but not limited to, hospital, doctor, nurse, therapy, psychiatric and/or psychological
records.
4. Any and all medical bills (paid or owing) incurred as a result of the lawsuit incident.
4833-0167-3676.1
*** FILED: PALM BEACH COUNTY, FL SHARON R BOCK, CLERK. 09/21/2020 04:44:52 PM ***CASE NO.: 50-2020-CA-007743 (AN)
5. Any and all medical records for treatment received by the plaintiff in the five year
period prior to the lawsuit incident, including, but not limited to, hospital, doctor, nurse, therapy,
psychiatric and/or psychological records.
6. Any and all documents or records pertaining to collateral source benefits of any
nature obtained by Plaintiff or to which Plaintiff may have a claim.
7. Any and all statements of any employee, agent or representative of defendant, its
employees or agents.
8. Any and all statements of any independent witnesses who observed the incident
complained of or who were on the scene immediately before or after the incident.
9. Any and all photographs taken at the scene of the incident on the date of incident or at
any other time.
10. Any photographs of Plaintiff showing his or her injury or condition after reaching
maximum medical improvement and his or her condition prior to the injuries complained of.
11. Any other photographs pertaining to the claims alleged in this action.
12. Complete cell phone billing records for the one hour period before the accident and
one hour after the subject accident.
13. Pharmacy records for a two-year period prior to the date of the accident.
14. Any notes, diaries, logs, journals, letters, electronic mail, text messages, calendars,
Facebook postings, tweets, or other social media messages that relate or refer to your accident, your
injuries, or travel or vacation activities since the date of accident.
15. Copies of all documents reflecting any claim Plaintiff has made in the past for
personal injury, wages or other compensation.
4833-0167-3676.1 2CASE NO.: 50-2020-CA-007743 (AN)
16. | A photocopy of any health insurance policies or records in the plaintiff's possession
for the last seven (7) years, or if unavailable, the name and address of any company who has custody
of such documents.
17. Copies of any disability insurance applications or other paperwork regarding
applications or policies in the last seven (7) years, or if unavailable, the name and address of any
company who has custody of such documents.
18. Please produce properly executed and completed authorizations for obtaining
information from the Social Security Administration relating to Plaintiff’ s earnings. (A copy of the
appropriate release form is attached hereto.)
19. Please produce properly executed and completed authorizations for obtaining true and
correct copies of Plaintiff's Federal Income Tax Returns for the three years prior to the year of
accident to date (Authorizations are attached hereto.)
20. Please produce properly executed HIPAA Authorization Form (attached hereto.)
21. Please produce properly executed and completed authorizations for obtaining
Plaintiffs Medicare and Florida Medicaid information (a copy of the appropriate authorizations are
attached hereto.)
22. Please produce properly executed and completed authorization for obtaining
Plaintiff's Social Security Administration records relating to any claims made by the Plaintiff
(a copy of the appropriate authorization is attached hereto.)
23. Proof that you area U.S. citizen or lawful permanent resident, including execution of
the attached Form G-639.
24. If youarenota U.S. citizen or lawful permanent resident, proof of your immigration
status.
25. Acopy of Plaintiff’s Florida Driver’s License.
4833-0167-3676.1 3CASE NO.: 50-2020-CA-007743 (AN)
26. Acopy of Plaintiff's PIP Insurance card or policy.
27. _ A copy of the registration for the vehicle driven by Plaintiff at the time of the
accident.
28. Acopy of the ticket/citation, if any, issued to Plaintiff at the time of the accident by
police.
29. To the extent not requested above, any and all documents that support any of the
claims in this action.
CERTIFICATE OF SERVICE
WE HEREBY CERTIFY that we electronically filed the foregoing with the Clerk of the
Court by using the Florida Courts E-Filing Portal which will send a Notice of Electronic Filing to:
Carlos Jimenez, Esq., and Scott Goldstein, Esq., CARLOS J. JIMENEZ, P.L., 1880 North Congress
Avenue, Suite 315, Boynton Beach, FL 33426, Counsel for Plaintiff, eService@247Injurylaw.com;
by e-mail on September 21, 2020.
LEWIS BRISBOIS BISGAARD & SMITH, LLP
Attorneys for Defendants
110 SE 6" Street, Suite 2600
Fort Lauderdale, FL 33301
(954)728-1280
(954)728-1282 fax
Jeffrey. Mowers@LewisBrisbois.com
Ellise.Silverberg@LewisBrisbois.com
Ftlemaildesig@LewisBrisbois.com
BY: _A/Jeffrey A. Mowers
JEFFREY A. MOWERS
FBN 508240
4833-0167-3676.1 4Form SSA-7050-F4 (03-2019)
Discontinue Prior Editions Page 1 of 4
Social Security Administration OMB No. 0960-0525
REQUEST FOR SOCIAL SECURITY EARNING INFORMATION
*Use This Form If You Need
DO NOT USE THIS FORM TO REQUEST
1. Certified/Non-Certified Detailed Earnings Information YEARLY EARNINGS TOTALS.
Includes periods of employment or self-employment
and the names and addresses of employers. Yearly earnings totals are free to the public
if you do not require certification.
2. Certified Yearly Totals of Earnings
Includes total earnings for each year but does not To obtain FREE yearly totals of earnings,
include the names and addresses of employers. visit our website at www.ssa.gov/myaccount.
Privacy Act Statement
Collection and Use of Personal Information
Section 205 of the Social Security Act, as amended, authorizes us to collect the information on this form. We will use the
information you provide to identify your records and send the earnings information you request. Completion of this form is
voluntary; however, failure to do so may prevent your request from being processed.
We rarely use the information in your earnings record for any purpose other than for determining your entitlement to
Social Security benefits. However, we may use it for the administration and integrity of Social Security programs. We may
also disclose information to another person or to another agency in accordance with approved routine uses, which
include but are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing rights to Social Security benefits
and/or coverage;
2. To comply with Federal laws requiring the release of information from Social Security records (e.g., to the
Government Accountability Office and Department of Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs at the Federal,
State, and local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity and
improvement of Social Security programs.
A ccomplete list of routine uses for earnings information is available in our Systems of Records Notices entitled, the
Earnings Recording and Self-Employment Income System (60-0059), the Master Beneficiary Record (60-0090), and the
SSA-Initiated Personal Earnings and Benefit Estimate Statement (60-0224). In addition, you may choose to pay for the
earnings information you requested with a credit card. 31 C.F.R. Part 206 specifically authorizes us to collect credit card
information. The information you provide about your credit card is voluntary. Providing payment information is only
necessary if you are making payment by credit card. You do not need to fill out the credit card information if you choose
another means of payment (for example, by check or money order). If you choose the credit card payment option, we will
provide the information you give us to the banks handling your credit card account and the Social Security
Administration's (SSA) account.
Routine uses applicable to credit card information, include but are not limited to: (1) to enable a third party or an agency
to assist Social Security to effect a salary or an administrative offset or to an agent of SSA that is a consumer reporting
agency for preparation of a commercial credit report in accordance with 31 U.S.C. §§ 3711, 3717, and 3718; and (2) toa
consumer reporting agency or debt collection agent to aid in the collection of outstanding debts to the Federal
Government. A complete list of routine uses for credit card information is available in our System of Records Notice
entitled, the Financial Transactions of SSA Accounting and Finance Offices (60-0231). The notice, additional information
regarding this form, routine uses of information, and our programs and systems is available on-line at
www.socialsecurity.gov or at your local Social Security office.
Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as
amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we
display a valid Office of Management and Budget control number. We estimate that it will take about 11 minutes to read
the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate above
to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.Form SSA-7050-F4 (03-2019) Page 2 of 4
REQUEST FOR SOCIAL SECURITY EARNING INFORMATION
1. Provide your name as it appears on your most recent Social Security card or the name of the individual whose
earnings you are requesting.
First Name: Middle Initial: [|
Last Name:
Social Security Number (SSN) One SSN per request
Date of Birth: Date of Death:
Other Name(s) Used
Maiden Name)
2. What kind of earnings information do you need? (Choose ONE of the following types of earnings or SSA must return
this request.)
[_] Itemized Statement of Earnings $91.00
(Includes the names and addresses of employers)
If you check this box, tell us why you need this Year(s) Requested: to
information below.
Year(s) Requested:}2}0|0/]9]/to |2/o0]1]/9
Check this box if you want the earnings
Plaintiff involved in a civil lawsuit CJ information CERTIFIED for an additional
$34.00 fee.
(J Certified Yearly Totals of Earnings $34.00 y R ted t
ear(s) Requested: lo
(Does not include the names and addresses of (s) Req
employers)Yearly eamings totals are FREE to the public if you .
do not require certification. To obtain FREE yearly totals of Year(s) Requested: La
earnings, visit our website at www.ssa.gov/myaccount.
3. If you would like this information sent to someone else, please fill in the information below.
| authorize the Social Security Administration to release the earnings information to:
Name Jeffrey A. Mowers, Esquire, c/o LEWIS BRISBOIS BISGAARD & SMITH, LLP
Address 110 S.E. 6th Street, Suite 2600 State FL
City Fort Lauderdale ZIP Code 33301
4. | am the individual to whom the record pertains (or a person authorized to sign on behalf of that individual). |
understand that any false representation to knowingly and willfully obtain information from Social Security records is
punishable by a fine of not more than $5,000 or one year in prison.
; : in ; SSA must receive this form within 120 days fi
Signature AND Printed Name of Individual or Legal Guardian negate signed
Date
Relationship (if applicable, you must attach proof) Daytime Phone:
Address State
City ZIP Code
Witnesses must sign this form ONLY if the above signature is by marked (X). If signed by mark (X), two witnesses to the
signing who know the signee must sign below and provide their full addresses. Please print the signee's name next to the
mark & on the signature line above.
1. Signature of Witness 2. Signature of Witness
Address (Number and Street, City, State and ZIP Code) Address (Number and Street, City, State and ZIP Code)Form SSA-7050-F4 (03-2019)
Page 3 of 4
REQUEST FOR SOCIAL SECURITY EARNING INFORMATION
INFORMATION ABOUT YOUR REQUEST
You may use this form to request earnings information for one ONE Social Security Number (SSN)
How do | get my earnings statement?
You must complete the attached form. Tell us the
specific years of earnings you want, type of earnings
record, and provide your mailing address. The itemized
statement of earnings will be mailed to ONE address,
therefore, if you want the statement sent to someone
other than yourself, provide their address in section 3.
Mail the completed form to SSA within 120 days of
signature. If you sign with an "X", your mark must be
witnessed by two impartial persons who must provide
their name and address in the spaces provided.
Select ONE type of earnings statement and include the
appropriate fee.
1. Certified/Non-Certified Itemized Statement of
Earnings
This statement includes years of self-employment or
employment and the names and addresses of
employers.
2. Certified Yearly Totals of Earnings
This statement includes the total earnings for each
year requested but does not include the names and
addresses of employers.
If you require one of each type of earnings statement,
you must complete two separate forms. Mail each form
to SSA with one form of payment attached to each
request.
How do | get someone else's earnings
statement?
You may get someone else's earnings information if you
meet one of the following criteria, attach the necessary
documents to show your entitlement to the earnings
information and include the appropriate fee.
1. Someone Else's Earnings
The natural or adoptive parent or legal guardian of a
minor child, or the legal guardian of a legally
declared incompetent individual, may obtain
earnings information if acting in the best interest of
the minor child or incompetent individual. You must
include proof of your relationship to the individual
with your request. The proof may include a birth
certificate, court order, adoption decree, or other
legally binding document.
2. A Deceased Person's Earnings
You can request earnings information from the
record of a deceased person if you are:
+ The legal representative of the estate;
+ A survivor (that is, the spouse, parent, child,
divorced spouse of divorced parent); or
+ An individual with a material interest (e.g.,
financial) who is an heir at law, next of kin,
beneficiary under the will or donee of property of
the decedent.
You must include proof of death and proof of your
relationship to the deceased with your request.
Is There A Fee For Earnings Information?
Yes. We charge a $91.00 fee for providing information
for purposes unrelated to the administration of our
programs.
1. Certified or Non-Certified Itemized Statement of
Earnings
In most instances, individuals request Itemized
Statements of Earnings for purposes unrelated to
our programs such as a private pension plan or
personal injury suit. Bulk submitters may email
OCO.Pension.Fund@ssa.gov for an alternate
method of obtaining itemized earnings information.
We will certify the itemized earnings information for
an additional $34.00 fee. Certification is usually not
necessary unless you are specifically requested to
obtain a certified earnings record.
Sometimes, there is no charge for itemized earnings
information. If you have reason to believe your
earnings are not correct (for example, you have
previously received earnings information from us
and it does not agree with your records), we will
supply you with more detail for the year(s) in
question. Be sure to show the year(s) involved on
the request form and explain why you need the
information. If you do not tell us why you need the
information, we will charge a fee.
2. Certified Yearly Totals of Earnings
We charge $34.00 to certify yearly totals of
earnings. However, if you do not want or need
certification, you may obtain yearly totals FREE of
charge at www.ssa.gov/myaccount. Certification is
usually not necessary unless you are advised
specifically to obtain a certified earnings record.
Method of Payment
This Fee Is Not Refundable. DO NOT SEND CASH.
You may pay by credit card, check or money order.
+ Credit Card Instructions
Complete the credit card section on page 4 and
return it with your request form.
* Check or Money Order Instructions
Enclose one check or money order per request
form payable to the Social Security
Administration and write the Social Security
number in the memo.
How long will it take SSA to process my request?
Please allow SSA 120 days to process this request.
After 120 days, you may contact 1-800-772-1213 to
leave an inquiry regarding your request.Form SSA-7050-F4 (03-2019)
Page 4 of 4
REQUEST FOR SOCIAL SECURITY EARNING INFORMATION
« Where do | send my complete request?
Mail the completed form, supporting documentation,
land applicable fee to:
Social Security Administration
P.O. Box 33011
Baltimore, Maryland 21290-33011
If using private contractor such as FedEx mail form,
supporting documentation, and application fee to:
Social Security Administration
P.O. Box 33011
Baltimore, Maryland 21290-33011
¢ How much do | have to pay for an Itemized Statement of Earnings?
Non-Certified Itemized Statement of Eamings
Certified Itemized Statement of Earnings
$91.00
$125.00
* How much do I have to pay for Certified Yearly Totals of Earnings?
Certified yearly totals of earnings cost $34.00. You may obtain non-certified yearly totals FREE of charge at
www.ssa.gov/myaccount. Certification is usually not necessary unless you are specifically asked to obtain a
certified earnings record.
YOU CAN MAKE YOUR PAYMENT BY CREDIT CARD
As a convenience, we offer you the option to make your payment by credit card. However, regular credit card rules will
apply. You also pay by check or money order. Make check payable to Social Security Administration.
CHECK ONE
O Visa
(MasterCard
(LD American Express
(J Discover
Credit Card Holder's Name
(Enter the name from the credit card)
First Name, Middle Initial, Last Name
Credit Card Holder's Address
Daytime Telephone Number
Credit Card Number
Number & Street
City, State, & ZIP Code
Area Code
Credit Card Expiration Date
(MM/YY)
Amount Charged
See above to select the correct fee for your request.
Applicable fees are $34.00, $91.00, or $125.00.
SSA will return forms without the appropriate fee.
Credit Card Holder's Signature
Date
DO NOT WRITE IN THIS SPACE
OFFICE USE ONLY
[Authorization
Name Date
Remittance Control #rom 4506 equest for opy of Tax eturn
(uly2017) > Do not sign this form unless all applicable lines have been completed. (OMB No. 1545-0429
tedetnore thar > Request may be rejected if the form is incomplete or illegible.
Internal Revenue Service > For more information about Form 4506, visit www irs gov/form4506.
Tip. You may be able to get your tax return or return information from other sources. If you had your tax return completed by a paid preparer, they
should be able to provide you a copy of the return. The IRS can provide a Tax Return 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 (uch as a mortgage company)
requires. See Form 4506-T, Request for Transcript of Tax Return, or you can quickly request transcripts by using our automated self-help service
tools. Please visit us at IRS.gov and click on “Get a Tax Transcript...” or call 1-800-908-9946.
da Name shown on tax return. If a joint return, enter the name shown first. 1b
social security number on tax return,
individual taxpayer identification number, or
employer identification number (see instructions)
2a If ajoint return, enter spouse’s name shown on fax return. 2b Second social security number or individual
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 Ifthe tax retum is to be mailed to a third party (such as a mortgage company), enter the third party's name, address, and telephone number.
deffrey A, Mowers Esquire, Lewis Brisbois Bisqaard | Smith LLP
110 S.E. 6th Street Suite 2600 Fort Lauderdale FL 33301 Telephone: 954 728 1280
Caution: If the tax retum is being mailed to a third party, ensure that you have filled in lines 6 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
5, the IRS has no control over 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 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: if the copies must be certified for court or administrative proceedings, checkhere . . Feet
7 Year or period requested. Enter the ending date of the year or period, using the mm/dd/yyyy format. If you are requesting more than
eight years or periods, you must attach another Form 4506.
12/31/15 12/31/16 12/31/17 12/31/18
12/31/19
8 Fee. There isa 50 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.
a Costforeachretum . . . ee ee eee ee eee eee et 50.00
b Number of returns requested on in oe 5
© Total cost. Multiply line 8abyline8b . . . 250.00
@ If we cannot find the tax return, we wil refund the fee. I the refund should go to the Third party lsted on Tina 5, chack here
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 1a or 2a, or a person authorized to obtain the tax retum
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 I have the authority to
execute Form 4506 on behalf of the taxpayer. Note: This form must be received by IRS within 120 days of the signature date.
U 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. re ner of taxpayer on line
Sign y Signature (see instructions) Date
Here
y Title (fine Ta above is a corporation, partnership, estate, or trust)
) Spouse’s signature Date
For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 41721€ Form 4506 (Rev. 7-2017)Form 4506 (Rev. 7-2017)
Page 2
Section references are to the Internal Revenue Code
unless otherwise noted.
Future Developments
For the latest information about Form 4506 and its
instructions, go to www irs goviform4506.
Information about any recent developments affecting
Form 4508, Form 4508-T and Form 4506T-EZ will be
posted on that page.
General Instructions
Caution: Do not sign this form unless all applicable
lines have been complete
Purpose of form. Use Form 4506 to request a copy
of your tax return. You can also designate (on line 5)
a third party to receive the tax return.
How long will it take? It may take up to 75
calendar days for us to process your request.
Tip. Use Form 4506-T, Request for Transcript of Tax
Return, to request tax return transcripts, tax account
information, W-2 information, 1099 information,
verification of nonfiling, and records of account.
Automated transcript request. You can quickly
request transcripts by using our automated self-help
service tools. Please visit us at IRS. gov and click on
“Get a Tax Transcript...” or call 1-800-908-9946.
Where to file. Attach payment and mail Form 4506
to the address below for the state you lived in, or the
state your business was in, when that return was
filed. There are two address charts: one for
individual returns (Form 1040 series) and one for all
other returns.
If you are requesting a return for more than one
year or period and the chart below shows two
different addresses, send your request to the
address based on the address of your most recent
retum,
Chart for individual returns
(Form 1040 series)
i ee filed an
Mail to:
‘Alabama, Kentucky,
Louisiana, Mississippi,
Tennessee, Texas, a
foreign country, American
Samoa, Puerto Rico,
Guam, the
Commonwealth of the
Northern Mariana Islands,
the U.S. Virgin Islands, or
AP.O. or F.P.O. address
Intemal Revenue Service
RAIVS Team
Stop 6716 AUSC.
Austin, TX 73301
‘Alaska, Arizona,
Arkansas, California,
Colorado, Hawaii, Idaho,
llinois, indiana, lowa,
Kansas, Michigan,
Minnesota, Montana,
Nebraska, Nevada, New
Mexico, North Dakota,
‘Oklahoma, Oregon,
South Dakota, Utah,
Washington, Wisconsin,
Wyoming
Intemal Revenue Service
RAIVS Team
Stop 37106
Fresno, CA 93888
Connecticut,
Delaware, District of
Columbia, Florida,
Georgia, Maine,
Maryland, Intemal Revenue Service
Massachusetts, RAIVS Team
Missouri, New ‘Stop 6705 P-6
Hampshire, New Jersey, ‘
New York, North eee
Carolina, Ohio,
Pennsylvania, Rhode
Island, South Carolina,
Vermont, Virginia, West
Virginia
Chart for all other returns
It you lived in
or your business
was
Mail to:
Alabama, Alaska,
Arizona, Arkansas,
California, Colorado,
Florida, Hawaii, Idaho,
lowa, Kansas, Louisiana,
Minnesota, Mississippi,
Missouri, Montana,
Nebraska, Nevada,
New Mexico,
North Dakota,
Oklahoma, Oregon,
South Dakota, Texas,
Utah, Washington,
Wyoming, a foreign
country, American
‘Samoa, Puerto Rico,
Guam, the
Commonwealth of the
Northern Mariana
Islands, the U.S. Virgin
Islands, or A.P.O. or
F.P.O. address
Internal Revenue Service
RAIVS Team
P.O. Box 9941
Mail Stop 6734
Ogden, UT 84409
Connecticut, Delaware,
District of Columbia,
Georgia, Illinois, Indiana,
Kentucky, Maine,
Maryland,
Massachusetts, Internal Revenue Service
Michigan, New RAIVS Team,
Hampshire, New Jersey, P.O. Box 146500
New York, North step 2800 F
Carolina,
Ohio, Pennsylvania,
Rhode Island, South
Carolina, Tennessee,
Vermont, Viginia, West
ia, Wisconsin
inati, OH 45250
Specific Instructions
Line 1b. Enter your employer identification number
(EIN) if you are requesting a copy of a business
retum. Otherwise, enter the first social security
number (SSN) or your individual taxpayer
identification number (ITIN) shown on the return. For
‘example, if you are requesting Form 1040 that
includes Schedule G (Form 1040), enter your SSN.
Line 3, Enter your current address. If you use a P.O.
box, please include it on this line 3.
Line 4. Enter the address shown on the last return
filed if different from the address entered on line 3.
Note: If the addresses on lines 3 and 4 are different
and you have not changed your address with the
IRS, file Form 8822, Change of Address. For a
business address, file Form 8822-B, Change of
Address or Responsible Party — Business.
‘Signature and date. Form 4506 must be signed and
dated by the taxpayer listed on line 1a or 2a. The
IRS must receive Form 4506 within 120 days of the
date signed by the taxpayer or it will be rejected.
Ensure that all applicable lines are completed before
signing.
You must check the box in the
signature area to acknowledge you
have the authority to sign and request
the information The form will not be
processed and returned to you if the box is
unchecked
Individuals Copies of jointly filed tax returns may
be furnished to either spouse. Only one signature is
required. Sign Form 4506 exactly as your name
appeared on the original return. If you changed your
name, also sign your current name.
Corporations Generally, Form 4506 can be
signed by: (1) an officer having legal authority to bind
the corporation, (2) any person designated by the
board of directors or other governing body, or (3)
any officer or employee on written request by any
principal officer and attested to by the secretary or
other officer. A bona fide shareholder of record
owning 1 percent or more of the outstanding stock
of the corporation may submit a Form 4506 but must
provide documentation to support the requester's
right to receive the information
Partnerships Generally, Form 4506 can be
signed by any person who was a member of the
partnership during any part of the tax period
requested on line 7.
All others See section 6103(e) if the taxpayer has
died, is insolvent, is a dissolved corporation, or if @
trustee, guardian, executor, receiver, or
administrator is acting for the taxpayer.
Note: If you are Heir at law, Next of kin, or
Beneficiary you must be able to establish a material
interest in the estate or trust.
Documentation. For entities other than individuals,
you must attach the authorization document. For
example, this could be the letter from the principal
officer authorizing an employee of the corporation or
the letters testamentary authorizing an individual to
act for an estate.
Signature by a representative. A representative
can sign Form 4506 for a taxpayer ony if this
authority has been specifically delegated to the
representative on Form 2848, line 5. Form 2848
showing the delegation must be attached to Form
506.
Privacy Act and Paperwork Reduction Act
Notice. We ask for the information on this form to
establish your right to gain access to the requested
return(s) under the Internal Revenue Code. We need
this information to properly identify the return(s) and
respond to your request. If you request a copy of a
tax retum, sections 6103 and 6109 require you to
provide this information, including your SSN or EIN,
to process your request. If you do not provide this.
information, we may not be able to process your
request. Providing false or fraudulent information
may subject you to penalties,
Routine uses of this information include giving it to
the Department of Justice for civil and criminal
litigation, and cities, states, the District of Columbia,
and U.S. commonwealths and possessions for use
in admi their tax laws. We may also
disclose this information to other countries under a
tax treaty, to federal and state agencies to enforce
federal nontax criminal laws, or to federal law
enforcement and intelligence agencies to combat
terrorism.
You are not required to provide the information
requested on a form that is subject to the Paperwork
Reduction Act unless the form displays a valid OMB
control number. Books or records relating to a form
or its instructions must be retained as long as their
contents may become material in the administration,
of any Internal Revenue law. Generally, tax returns,
and return information are confidential, as required
by section 6103.
The time needed to complete and file Form 4508
will vary depending on individual circumstances. The
estimated average time is: Learning about the law
or the form, 10 min.; Preparing the form, 16 min.;
and Copying, assembling, and sending the form
to the IRS, 20 min.
Ifyou have comments concerning the accuracy of
these time estimates or suggestions for making
Form 4506 simpler, we would be happy to hear from
you. You can write to:
Internal Revenue Service
Tax Forms and Publications Division
1111 Constitution Ave. NW, IR-6526
Washington, DC 20224,
Do not send the form to this address. Instead, see
Where to file on this page.rom 4506T-EZ| Short orm Request for Individual Tax Return Transcript
(July 2017) OMB No. 1545-2154
> Request may not be processed if the form is incomplete or illegible.
Department of the Treasury 7 7
Internal Revenue Service > For more information about Form 4506T-EZ, visit www irs gov/form4506tez.
Tip. Use Form 4506T-EZ to order a 1040 series tax return transcript free of charge, or you can quickly request transcripts by using our automated self-help
service tools. Please visit us at IRS.gov and click on “Get Transcript of Your Tax Records” under “Tools” or call 1-800-908-9946.
a Name shown on tax return. If a joint return, enter the name shown first. 1b Fir
social security number or individual taxpayer
lentification number on tax return
2a If ajoint return, enter spouse’s name shown on tax return. 2b Second social security number or indivi
taxpayer identification number if j
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 transcript is to be mailed to a third party (such as a mortgage company), enter the third party's name, address, and telephone number. The
IRS has no control over what the third party does with the tax information.
Third party name Telephone number
Jeffrey A. Mowers Esq. c/o Lewis Brisbois Bisqaard Smith LLP 954 728 1280
‘Address (including apt., room, or suite no), city, state, and ZIP code
110 S.E. 6th St. Suite 2600 Fort Lauderdale FL 33301
Caution. If the tax transcript is being mailed to a third party, ensure that you have filled in line 6 before signing. Sign and date the form once you have
filled in this line. Completing this step helps to protect your privacy. Once the IRS discloses your IRS transcript to the third party listed on line 5, the
IRS has no control over what the third party does with the information. If you would like to limit the third party s authority to disclose your transcript
information, you can specify this limitation in your written agreement with the third party.
6 Years) requested. Enter the year(s) of the return transcript you are requesting (for example, “2008”). Most requests will be processed within
10 business days.
2017 2018 2019
Note. /f the IRS is unable to locate a return that matches the taxpayer identity information provided above or if IRS records indicate that the return has
not been filed the IRS will notify you or the third party that it was unable to locate a return or that a return was not filed whichever is applicable.
Caution. Do not sign this form unless all applicable lines have been completed.
Signature of taxpayer s). | declare that | am the taxpayer whose name is shown on either line 1a or 2a. If the request applies to a joint return, either
‘spouse must sign. Note: This form must be received by IRS within 120 days of the signature date.
O 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-T. See instructions.
Phone number of taxpayer
‘on line 1a or 2a
Sign
» ‘Signature (see instructions) Date
Here
U Spouse’s signature Date
For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 54185S Form 4506T-EZ (Rev. 7-2017)Form 4506T-EZ (Rev. 7-2017)
Page 2
Section references are to the Internal Revenue
Code unless otherwise noted.
Future Developments
For the latest information about developments
related to Form 4506T-EZ, such as legislation
enacted after it was published, go to
www.irs.gov/form4s06tez.
Caution. Do not sign this form unless all
applicable lines have been completed.
Purpose of form. Individuals can use Form
4506T-EZ to request a tax return transcript for
the current and the prior three years that
includes most lines of the original tax return.
The tax return transcript will not show
payments, penalty assessments, or
adjustments made to the originally filed
return. You can also designate (on line 5) a
third party (such as a mortgage company) to
receive a transcript. Form 4506T-EZ cannot
be used by taxpayers who file Form 1040
based ona tax year beginning in one calendar
year and ending in the following year (fiscal
tax year). Taxpayers using a fiscal tax year
must file Form 4506-T, Request for Transcript
of Tax Return, to request a return transcript.
Use Form 4506-T to request tax return
transcripts, tax account information, W-2
information, 1099 information, verification of
non-filing, and record of account.
Automated transcript request. You can
quickly request transcripts by using our
automated self-help service tools. Please visit
us at IRS.gov and click on “Get Transcript of
Your Tax Records” under “Tools” or call
1-800-908-9946.
Where to file. Mail or fax Form 4506T-EZ to
the address below for the state you lived in
when the return was filed.
If you are requesting more than one
transcript or other product and the chart
below shows two different addresses, send
your request to the address based on the
address of your most recent return.
If you filed an Mail or fax to the
individual return “Internal Revenue
and lived in: Service” at:
Alabama, Kentucky,
Louisiana,
Mississippi,
Tennessee, Texas, a
foreign country,
7 RAIVS Team
American Samoa, Stop 6716 AUSC
Puerto Rico, Guam,
the Commonwealth
of the Northern
Mariana Islands, the
U.S. Virgin Islands, or
A-P.O. or F.P.O.
address
Alaska, Arizona,
Arkansas, California,
Colorado, Hawaii,
Austin, TX 73301
855-587-9604
Idaho, Illinois,
Indiana, lowa,
Kansas, Michigan, RAIVS Team
Minnesota, Montana, | Stop 37106
Nebraska, Nevada,
New Mexico, North
Dakota, Oklahoma,
Oregon, South
Dakota, Utah,
Washington,
Wisconsin, Wyoming
Connecticut,
Delaware, District of
Columbia, Florida,
Georgia, Maine,
Fresno, CA 93888
(855) 800-8105
Maryland,
Massachusetts, preload
lassach Stop 6705 P-6
Missouri, New ee oe
Hampshire, New eames
Jersey, New York,
North Carolina, Ohio,
Pennsylvania, Rhode
Island, South
Carolina, Vermont,
Virginia, West Virginia
Line 1b. Enter your employer identification
number (EIN) if your request relates to a
business return. Otherwise, enter the first
social security number (SSN) or your
individual taxpayer identification number (|TIN)
shown on the return. For example, if you are
requesting Form 1040 that includes Schedule
C (Form 1040), enter your SSN.
Line 3. Enter your current address. If you use
aP.O. box, include it on this line.
Line 4. Enter the address shown on the last
return filed if different from the address
entered on line 3.
Note. If the address on lines 3 and 4 are
different and you have not changed your
address with the IRS, file Form 8822, Change
of Address.
Signature and date. Form 4506T-EZ must be
signed and dated by the taxpayer listed on
line 1a or 2a. The IRS must receive Form
4506T-EZ within 120 days of the date signed
by the taxpayer or it will be rejected. Ensure
that all applicable lines are completed before
signing.
You must check the box in the signature area
to acknowledge you have the authority to sign
and request the information. The form will not
be processed and returned to you if the box is
unchecked
855-821-0094
Transcripts of jointly filed tax returns may
be furnished to either spouse. Only one
signature is required. Sign Form 4506T-EZ
exactly as your name appeared on the original
return. If you changed your name, also sign
your current name.
Privacy Act and Paperwork Reduction Act
Notice. We ask for the information on this
form to establish your right to gain access to
the requested tax information under the
Internal Revenue Code. We need this
information to properly identity the tax
information and respond to your request. If
you request a transcript, sections 6103 and
6109 require you to provide this information,
including your SSN. If you do not provide this
information, we may not be able to process
your request. Providing false or fraudulent
information may subject you to penalties.
Routine uses of this information include
giving it to the Department of Justice for civil
and criminal litigation, and cities, states, the
District of Columbia, and U.S.
commonwealths and possessions for use in
administering their tax laws. We may also
disclose this information to other countries
under a tax treaty, to federal and state
agencies to enforce federal nontax criminal
laws, or to federal law enforcement and
intelligence agencies to combat terrorism.
You are not required to provide the
information requested on a form that is
subject to the Paperwork Reduction Act
unless the form displays a valid OMB control
number. Books or records relating to a form
or its instructions must be retained as long as
their contents may become material in the
administration of any Internal Revenue law.
Generally, tax returns and return information
are confidential, as required by section 6103.
The time needed to complete and file Form
4506T-EZ will vary depending on individual
circumstances. The estimated average time
is: Learning about the law or the form, 9
min.; Preparing the form, 18 min.; and
Copying, assembling, and sending the form
to the IRS, 20 min.
If you have comments concerning the
accuracy of these time estimates or
suggestions for making Form 4506T-EZ
simpler, we would be happy to hear from you.
You can write to:
Internal Revenue Service
Tax Forms and Publications Division
1111 Constitution Ave. NW, IR-6526
Washington, DC 20224
Do not send the form to this address.
Instead, see Where to file on this page.HIPAA AUTHORIZATION FORM
I hereby authorize use of disclosure of protected health information about me as describe
below.
1. The following specific person or class of persons or facility is authorized to
make the requested use of disclosure:
Hospitals, all treating practitioners or other healthcare providers, physical
therapy, x-rays, prescriptions/medications.
2. The following person or class of persons may receive disclosure of protected
health information about me:
The attorneys representing Defendants in the case of
JUSTINO VEGA PENA and JUSTIN WILLIE VEGA v. SONY JOSEPH
and HL UNIVERSAL, INC., a Florida Profit Corporation
Case No.: 50-2020-CA-007743 (AN)
His/Her name is: Jeffrey A. Mowers, Attorney for Defendants
His/Her address is:_110 SE 6 Street, Suite 2600, Fort Lauderdale, Florida 33301
3. The specific information that should be disclosed is:
All medical and billing records
4. | understand that the information used or disclosed may be subject to re-
disclosure by counsel for Defendants for purposes of defending the lawsuit.
5. | understand that this authorization is voluntary. While | understand that |
have the right to revoke this authorization in writing submitted to counsel for Defendants, |
agree that any revocation may impact my ability to further prosecute the pending litigation
should a court so order.
Justino Vega Pena Date
Date of Birth
4831-4229-1284.1
4826-5276-9545.1A: if ED)
FIRST COAST
SERVICE OPTIONS INC.
A GIS Contracien hirenvevinny & CARRIER MEDICARE
Cnas/
CRS er sarc EDC Be,
Freedom of Information
AUTHORIZATION TO SHARE “PROTECTED HEALTH INFORM. ATION®
PURPOSE:
The purpose of this authorization is to Permit Medicare to release to a third Party, SuCh as someone other than the
benesiciary, my Protected Health infonnat! ‘on, specific to my Medicare records and/or claim information,
SECTION:
Please provide the following information regarding the beneficiary whose Protected Health Infozmation is to be
disclosed, (Please Print)
Name:
Address:
Telephone: Daytime Evening
Date of Birth: Medicare Number:
oe SSeS
SECTION Hi:
J hereby authorize Medicare to share the following Protected Health Information concerning me:
CJ Identifying information (e.g. name, address, age, gender);
Health care Coverage information;
Claim information for Date(s) to :
Past, present and future claim information;
SECTION HL:
Please identify the Person(s) or orgenization(s) with whom Medicare may share your Protected Health
Information:
Name; —
~. SECRECY
Address: Jeffrey A.M. aire
——— LEWIS F GAARD & SMITH, LLP Oe
te 2600
Fort ieuderdate, FT. 33301
——_! Sa aeSECTION iV:
Please enter a date OR select an event, upon which you want this authorization to expire,
‘This authorization will expire: Hh, eb i.
Month Day Year
OR:
When my Medicare coverage ends
SECTION V: .
You have the right to take back (“ Tevoke”) your authorization at any time, in writing, except to the extent that
Medicare has already ‘acted based on your permission: To revoke your authorization, sené a written request to:
First Coast Service Options, Inc,
Medicare Freedom of Information Coordinator
PO BOX 2078
1 Jacksonville, Florida 32231-0048
4
T understand refusal to authorize disclosure of my Protected Health Information will have no effect on my
enrollment, eligibility, for benefits, or the amount Medizare pays for the health services [ receive,
Your Protected Health Information that yau authorize Medicare to disclose may be subject to redisciesure and no
longer protected by law.
A photocopy of this authorization is as valid as the original
SIGNATURE:
Beneficiary Signature; Date:
Ifsomeone else is signing this authorization form on behalf of the beneficiary, pleasé provide the following
information: ,
Legal Representative*:
Date Signed: __
Relationship to the beneficiary:
* Documentation must be provided to support your stat us as a guardian or ether legal representative *
Please complete the entire form and return with a written request to:
First Coast Service Options, Inc
Atin: Medicare Freedom of Information
PO BOX 2078
Jacksonville Florida 32231-0048FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION,
RICK SCOTT dj: ELIZABETH DUDEK
GOVERNOR Better Health Care for all Floridians SECRETARY
Authorization for the Use and Disclosure of Protected Health Information
Federal law states that we cannot share an individual's health information without the individual’s permission, except in certain situations.
By signing this form, you are giving us permission to share th
formation you indicate below. If you decide later that you do not want us to
share this information any more, you can revoke this authorization at any time in writing or sign the REVOCATION SECTION on the back of
this form and return it to Xerox Recovery Services. This form must be completed and signed by the Medicaid recipient or by an in
ual
who has the authority to act on the Medicaid recipient's behalf (parent of a minor, legal guardian, trustee, power of attorney, personal
representative of the estate, grantor of an annuity).
1.
3.
4.
PLEASE COMPLETE THE FOLLOWING SECTIONS
Personal Information:
Medicaid Recipient's Name, Date of Birth,
Medicaid ID Number. Social Security Number,
| give permission to the Agency for Health Care Administration (AHCA) and its contract representatives to share the health information
listed below with the following: ervey BROS BARD ene
110 S.E. 6th Street, Suite 2600
Name of the Law Firm or Law Office_Fort Lauderdale, FL 33301
Name of the Insurance Company,
Other,
Indicate the purpose for which the disclosure is to be made:
To substantiate Medicaid’s lien relating to a lawsuit
To substantiate Medicaid’s claim against the estate or against a trust account or annuity
Other
Indicate the information that you want to be disclosed, related to the following (check one):
__The Medicaid lien relating to the injury or negligence charges, for the period beginning with the date of incident.
__Medicaid’s claim against the estate.
__The amount that is due Medicaid from the trust account, [Please send a copy of the trust agreement].
__The amount that is due Medicaid from the annuity account, [Please send a copy of the annuity agreement].
__ Other, [Please be specific}.
Enter the specific date that you want this authorization to expire: (i.e., one year from date of release).
(If you do not enter a date, this authorization will expire in five years.)
| understand that the information described above may be redisclosed by the p
Preview
Filing # 113712292 E-Filed 09/21/2020 04:44:52 PM IN THE CIRCUIT COURT OF THE FIFTEENTH JUDICIAL CIRCUIT IN AND FOR PALM BEACH COUNTY, FLORIDA CIRCUIT CIVIL DIVISION CASE NO.: 50-2020-CA-007743 (AN) JUSTINO VEGA PENA and JUSTIN WILLIE VEGA, Plaintiff, v. SONY JOSEPH and HL UNIVERSAL, INC., a Florida Profit Corporation, Defendants. / DEFENDANTS’ FIRST REQUEST FOR PRODUCTION TO PLAINTIFF, JUSTINO VEGA PENA COMES NOW Defendants, by and through their undersigned counsel, and requests that Plaintiff, JUSTINO VEGA PENA produce the following for inspection and/or copying at the offices of Lewis Brisbois Bisgaard & Smith LLP, Attorneys for Defendants, 110 SE 6" Street, Suite 2600, Fort Lauderdale, Florida 33301 within thirty (30) days from the date hereof pursuant to Rule 1.350, Fla.R.Civ.P. 1. Copies of Income Tax Returns, including all schedules, attachments and W2 forms, or a properly executed authorization for obtaining a true copy of Federal Income Tax Retums for the three year period prior to the date of accident to date. 2. A record of earings for the current year to date. 3. Any and all medical records for treatment resulting from the lawsuit incident including, but not limited to, hospital, doctor, nurse, therapy, psychiatric and/or psychological records. 4. Any and all medical bills (paid or owing) incurred as a result of the lawsuit incident. 4833-0167-3676.1 *** FILED: PALM BEACH COUNTY, FL SHARON R BOCK, CLERK. 09/21/2020 04:44:52 PM ***CASE NO.: 50-2020-CA-007743 (AN) 5. Any and all medical records for treatment received by the plaintiff in the five year period prior to the lawsuit incident, including, but not limited to, hospital, doctor, nurse, therapy, psychiatric and/or psychological records. 6. Any and all documents or records pertaining to collateral source benefits of any nature obtained by Plaintiff or to which Plaintiff may have a claim. 7. Any and all statements of any employee, agent or representative of defendant, its employees or agents. 8. Any and all statements of any independent witnesses who observed the incident complained of or who were on the scene immediately before or after the incident. 9. Any and all photographs taken at the scene of the incident on the date of incident or at any other time. 10. Any photographs of Plaintiff showing his or her injury or condition after reaching maximum medical improvement and his or her condition prior to the injuries complained of. 11. Any other photographs pertaining to the claims alleged in this action. 12. Complete cell phone billing records for the one hour period before the accident and one hour after the subject accident. 13. Pharmacy records for a two-year period prior to the date of the accident. 14. Any notes, diaries, logs, journals, letters, electronic mail, text messages, calendars, Facebook postings, tweets, or other social media messages that relate or refer to your accident, your injuries, or travel or vacation activities since the date of accident. 15. Copies of all documents reflecting any claim Plaintiff has made in the past for personal injury, wages or other compensation. 4833-0167-3676.1 2CASE NO.: 50-2020-CA-007743 (AN) 16. | A photocopy of any health insurance policies or records in the plaintiff's possession for the last seven (7) years, or if unavailable, the name and address of any company who has custody of such documents. 17. Copies of any disability insurance applications or other paperwork regarding applications or policies in the last seven (7) years, or if unavailable, the name and address of any company who has custody of such documents. 18. Please produce properly executed and completed authorizations for obtaining information from the Social Security Administration relating to Plaintiff’ s earnings. (A copy of the appropriate release form is attached hereto.) 19. Please produce properly executed and completed authorizations for obtaining true and correct copies of Plaintiff's Federal Income Tax Returns for the three years prior to the year of accident to date (Authorizations are attached hereto.) 20. Please produce properly executed HIPAA Authorization Form (attached hereto.) 21. Please produce properly executed and completed authorizations for obtaining Plaintiffs Medicare and Florida Medicaid information (a copy of the appropriate authorizations are attached hereto.) 22. Please produce properly executed and completed authorization for obtaining Plaintiff's Social Security Administration records relating to any claims made by the Plaintiff (a copy of the appropriate authorization is attached hereto.) 23. Proof that you area U.S. citizen or lawful permanent resident, including execution of the attached Form G-639. 24. If youarenota U.S. citizen or lawful permanent resident, proof of your immigration status. 25. Acopy of Plaintiff’s Florida Driver’s License. 4833-0167-3676.1 3CASE NO.: 50-2020-CA-007743 (AN) 26. Acopy of Plaintiff's PIP Insurance card or policy. 27. _ A copy of the registration for the vehicle driven by Plaintiff at the time of the accident. 28. Acopy of the ticket/citation, if any, issued to Plaintiff at the time of the accident by police. 29. To the extent not requested above, any and all documents that support any of the claims in this action. CERTIFICATE OF SERVICE WE HEREBY CERTIFY that we electronically filed the foregoing with the Clerk of the Court by using the Florida Courts E-Filing Portal which will send a Notice of Electronic Filing to: Carlos Jimenez, Esq., and Scott Goldstein, Esq., CARLOS J. JIMENEZ, P.L., 1880 North Congress Avenue, Suite 315, Boynton Beach, FL 33426, Counsel for Plaintiff, eService@247Injurylaw.com; by e-mail on September 21, 2020. LEWIS BRISBOIS BISGAARD & SMITH, LLP Attorneys for Defendants 110 SE 6" Street, Suite 2600 Fort Lauderdale, FL 33301 (954)728-1280 (954)728-1282 fax Jeffrey. Mowers@LewisBrisbois.com Ellise.Silverberg@LewisBrisbois.com Ftlemaildesig@LewisBrisbois.com BY: _A/Jeffrey A. Mowers JEFFREY A. MOWERS FBN 508240 4833-0167-3676.1 4Form SSA-7050-F4 (03-2019) Discontinue Prior Editions Page 1 of 4 Social Security Administration OMB No. 0960-0525 REQUEST FOR SOCIAL SECURITY EARNING INFORMATION *Use This Form If You Need DO NOT USE THIS FORM TO REQUEST 1. Certified/Non-Certified Detailed Earnings Information YEARLY EARNINGS TOTALS. Includes periods of employment or self-employment and the names and addresses of employers. Yearly earnings totals are free to the public if you do not require certification. 2. Certified Yearly Totals of Earnings Includes total earnings for each year but does not To obtain FREE yearly totals of earnings, include the names and addresses of employers. visit our website at www.ssa.gov/myaccount. Privacy Act Statement Collection and Use of Personal Information Section 205 of the Social Security Act, as amended, authorizes us to collect the information on this form. We will use the information you provide to identify your records and send the earnings information you request. Completion of this form is voluntary; however, failure to do so may prevent your request from being processed. We rarely use the information in your earnings record for any purpose other than for determining your entitlement to Social Security benefits. However, we may use it for the administration and integrity of Social Security programs. We may also disclose information to another person or to another agency in accordance with approved routine uses, which include but are not limited to the following: 1. To enable a third party or an agency to assist Social Security in establishing rights to Social Security benefits and/or coverage; 2. To comply with Federal laws requiring the release of information from Social Security records (e.g., to the Government Accountability Office and Department of Veterans’ Affairs); 3. To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and local level; and, 4. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity and improvement of Social Security programs. A ccomplete list of routine uses for earnings information is available in our Systems of Records Notices entitled, the Earnings Recording and Self-Employment Income System (60-0059), the Master Beneficiary Record (60-0090), and the SSA-Initiated Personal Earnings and Benefit Estimate Statement (60-0224). In addition, you may choose to pay for the earnings information you requested with a credit card. 31 C.F.R. Part 206 specifically authorizes us to collect credit card information. The information you provide about your credit card is voluntary. Providing payment information is only necessary if you are making payment by credit card. You do not need to fill out the credit card information if you choose another means of payment (for example, by check or money order). If you choose the credit card payment option, we will provide the information you give us to the banks handling your credit card account and the Social Security Administration's (SSA) account. Routine uses applicable to credit card information, include but are not limited to: (1) to enable a third party or an agency to assist Social Security to effect a salary or an administrative offset or to an agent of SSA that is a consumer reporting agency for preparation of a commercial credit report in accordance with 31 U.S.C. §§ 3711, 3717, and 3718; and (2) toa consumer reporting agency or debt collection agent to aid in the collection of outstanding debts to the Federal Government. A complete list of routine uses for credit card information is available in our System of Records Notice entitled, the Financial Transactions of SSA Accounting and Finance Offices (60-0231). The notice, additional information regarding this form, routine uses of information, and our programs and systems is available on-line at www.socialsecurity.gov or at your local Social Security office. Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 11 minutes to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.Form SSA-7050-F4 (03-2019) Page 2 of 4 REQUEST FOR SOCIAL SECURITY EARNING INFORMATION 1. Provide your name as it appears on your most recent Social Security card or the name of the individual whose earnings you are requesting. First Name: Middle Initial: [| Last Name: Social Security Number (SSN) One SSN per request Date of Birth: Date of Death: Other Name(s) Used Maiden Name) 2. What kind of earnings information do you need? (Choose ONE of the following types of earnings or SSA must return this request.) [_] Itemized Statement of Earnings $91.00 (Includes the names and addresses of employers) If you check this box, tell us why you need this Year(s) Requested: to information below. Year(s) Requested:}2}0|0/]9]/to |2/o0]1]/9 Check this box if you want the earnings Plaintiff involved in a civil lawsuit CJ information CERTIFIED for an additional $34.00 fee. (J Certified Yearly Totals of Earnings $34.00 y R ted t ear(s) Requested: lo (Does not include the names and addresses of (s) Req employers)Yearly eamings totals are FREE to the public if you . do not require certification. To obtain FREE yearly totals of Year(s) Requested: La earnings, visit our website at www.ssa.gov/myaccount. 3. If you would like this information sent to someone else, please fill in the information below. | authorize the Social Security Administration to release the earnings information to: Name Jeffrey A. Mowers, Esquire, c/o LEWIS BRISBOIS BISGAARD & SMITH, LLP Address 110 S.E. 6th Street, Suite 2600 State FL City Fort Lauderdale ZIP Code 33301 4. | am the individual to whom the record pertains (or a person authorized to sign on behalf of that individual). | understand that any false representation to knowingly and willfully obtain information from Social Security records is punishable by a fine of not more than $5,000 or one year in prison. ; : in ; SSA must receive this form within 120 days fi Signature AND Printed Name of Individual or Legal Guardian negate signed Date Relationship (if applicable, you must attach proof) Daytime Phone: Address State City ZIP Code Witnesses must sign this form ONLY if the above signature is by marked (X). If signed by mark (X), two witnesses to the signing who know the signee must sign below and provide their full addresses. Please print the signee's name next to the mark & on the signature line above. 1. Signature of Witness 2. Signature of Witness Address (Number and Street, City, State and ZIP Code) Address (Number and Street, City, State and ZIP Code)Form SSA-7050-F4 (03-2019) Page 3 of 4 REQUEST FOR SOCIAL SECURITY EARNING INFORMATION INFORMATION ABOUT YOUR REQUEST You may use this form to request earnings information for one ONE Social Security Number (SSN) How do | get my earnings statement? You must complete the attached form. Tell us the specific years of earnings you want, type of earnings record, and provide your mailing address. The itemized statement of earnings will be mailed to ONE address, therefore, if you want the statement sent to someone other than yourself, provide their address in section 3. Mail the completed form to SSA within 120 days of signature. If you sign with an "X", your mark must be witnessed by two impartial persons who must provide their name and address in the spaces provided. Select ONE type of earnings statement and include the appropriate fee. 1. Certified/Non-Certified Itemized Statement of Earnings This statement includes years of self-employment or employment and the names and addresses of employers. 2. Certified Yearly Totals of Earnings This statement includes the total earnings for each year requested but does not include the names and addresses of employers. If you require one of each type of earnings statement, you must complete two separate forms. Mail each form to SSA with one form of payment attached to each request. How do | get someone else's earnings statement? You may get someone else's earnings information if you meet one of the following criteria, attach the necessary documents to show your entitlement to the earnings information and include the appropriate fee. 1. Someone Else's Earnings The natural or adoptive parent or legal guardian of a minor child, or the legal guardian of a legally declared incompetent individual, may obtain earnings information if acting in the best interest of the minor child or incompetent individual. You must include proof of your relationship to the individual with your request. The proof may include a birth certificate, court order, adoption decree, or other legally binding document. 2. A Deceased Person's Earnings You can request earnings information from the record of a deceased person if you are: + The legal representative of the estate; + A survivor (that is, the spouse, parent, child, divorced spouse of divorced parent); or + An individual with a material interest (e.g., financial) who is an heir at law, next of kin, beneficiary under the will or donee of property of the decedent. You must include proof of death and proof of your relationship to the deceased with your request. Is There A Fee For Earnings Information? Yes. We charge a $91.00 fee for providing information for purposes unrelated to the administration of our programs. 1. Certified or Non-Certified Itemized Statement of Earnings In most instances, individuals request Itemized Statements of Earnings for purposes unrelated to our programs such as a private pension plan or personal injury suit. Bulk submitters may email OCO.Pension.Fund@ssa.gov for an alternate method of obtaining itemized earnings information. We will certify the itemized earnings information for an additional $34.00 fee. Certification is usually not necessary unless you are specifically requested to obtain a certified earnings record. Sometimes, there is no charge for itemized earnings information. If you have reason to believe your earnings are not correct (for example, you have previously received earnings information from us and it does not agree with your records), we will supply you with more detail for the year(s) in question. Be sure to show the year(s) involved on the request form and explain why you need the information. If you do not tell us why you need the information, we will charge a fee. 2. Certified Yearly Totals of Earnings We charge $34.00 to certify yearly totals of earnings. However, if you do not want or need certification, you may obtain yearly totals FREE of charge at www.ssa.gov/myaccount. Certification is usually not necessary unless you are advised specifically to obtain a certified earnings record. Method of Payment This Fee Is Not Refundable. DO NOT SEND CASH. You may pay by credit card, check or money order. + Credit Card Instructions Complete the credit card section on page 4 and return it with your request form. * Check or Money Order Instructions Enclose one check or money order per request form payable to the Social Security Administration and write the Social Security number in the memo. How long will it take SSA to process my request? Please allow SSA 120 days to process this request. After 120 days, you may contact 1-800-772-1213 to leave an inquiry regarding your request.Form SSA-7050-F4 (03-2019) Page 4 of 4 REQUEST FOR SOCIAL SECURITY EARNING INFORMATION « Where do | send my complete request? Mail the completed form, supporting documentation, land applicable fee to: Social Security Administration P.O. Box 33011 Baltimore, Maryland 21290-33011 If using private contractor such as FedEx mail form, supporting documentation, and application fee to: Social Security Administration P.O. Box 33011 Baltimore, Maryland 21290-33011 ¢ How much do | have to pay for an Itemized Statement of Earnings? Non-Certified Itemized Statement of Eamings Certified Itemized Statement of Earnings $91.00 $125.00 * How much do I have to pay for Certified Yearly Totals of Earnings? Certified yearly totals of earnings cost $34.00. You may obtain non-certified yearly totals FREE of charge at www.ssa.gov/myaccount. Certification is usually not necessary unless you are specifically asked to obtain a certified earnings record. YOU CAN MAKE YOUR PAYMENT BY CREDIT CARD As a convenience, we offer you the option to make your payment by credit card. However, regular credit card rules will apply. You also pay by check or money order. Make check payable to Social Security Administration. CHECK ONE O Visa (MasterCard (LD American Express (J Discover Credit Card Holder's Name (Enter the name from the credit card) First Name, Middle Initial, Last Name Credit Card Holder's Address Daytime Telephone Number Credit Card Number Number & Street City, State, & ZIP Code Area Code Credit Card Expiration Date (MM/YY) Amount Charged See above to select the correct fee for your request. Applicable fees are $34.00, $91.00, or $125.00. SSA will return forms without the appropriate fee. Credit Card Holder's Signature Date DO NOT WRITE IN THIS SPACE OFFICE USE ONLY [Authorization Name Date Remittance Control #rom 4506 equest for opy of Tax eturn (uly2017) > Do not sign this form unless all applicable lines have been completed. (OMB No. 1545-0429 tedetnore thar > Request may be rejected if the form is incomplete or illegible. Internal Revenue Service > For more information about Form 4506, visit www irs gov/form4506. Tip. You may be able to get your tax return or return information from other sources. If you had your tax return completed by a paid preparer, they should be able to provide you a copy of the return. The IRS can provide a Tax Return 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 (uch as a mortgage company) requires. See Form 4506-T, Request for Transcript of Tax Return, or you can quickly request transcripts by using our automated self-help service tools. Please visit us at IRS.gov and click on “Get a Tax Transcript...” or call 1-800-908-9946. da Name shown on tax return. If a joint return, enter the name shown first. 1b social security number on tax return, individual taxpayer identification number, or employer identification number (see instructions) 2a If ajoint return, enter spouse’s name shown on fax return. 2b Second social security number or individual 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 Ifthe tax retum is to be mailed to a third party (such as a mortgage company), enter the third party's name, address, and telephone number. deffrey A, Mowers Esquire, Lewis Brisbois Bisqaard | Smith LLP 110 S.E. 6th Street Suite 2600 Fort Lauderdale FL 33301 Telephone: 954 728 1280 Caution: If the tax retum is being mailed to a third party, ensure that you have filled in lines 6 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 5, the IRS has no control over 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 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: if the copies must be certified for court or administrative proceedings, checkhere . . Feet 7 Year or period requested. Enter the ending date of the year or period, using the mm/dd/yyyy format. If you are requesting more than eight years or periods, you must attach another Form 4506. 12/31/15 12/31/16 12/31/17 12/31/18 12/31/19 8 Fee. There isa 50 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. a Costforeachretum . . . ee ee eee ee eee eee et 50.00 b Number of returns requested on in oe 5 © Total cost. Multiply line 8abyline8b . . . 250.00 @ If we cannot find the tax return, we wil refund the fee. I the refund should go to the Third party lsted on Tina 5, chack here 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 1a or 2a, or a person authorized to obtain the tax retum 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 I have the authority to execute Form 4506 on behalf of the taxpayer. Note: This form must be received by IRS within 120 days of the signature date. U 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. re ner of taxpayer on line Sign y Signature (see instructions) Date Here y Title (fine Ta above is a corporation, partnership, estate, or trust) ) Spouse’s signature Date For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 41721€ Form 4506 (Rev. 7-2017)Form 4506 (Rev. 7-2017) Page 2 Section references are to the Internal Revenue Code unless otherwise noted. Future Developments For the latest information about Form 4506 and its instructions, go to www irs goviform4506. Information about any recent developments affecting Form 4508, Form 4508-T and Form 4506T-EZ will be posted on that page. General Instructions Caution: Do not sign this form unless all applicable lines have been complete Purpose of form. Use Form 4506 to request a copy of your tax return. You can also designate (on line 5) a third party to receive the tax return. How long will it take? It may take up to 75 calendar days for us to process your request. Tip. Use Form 4506-T, Request for Transcript of Tax Return, to request tax return transcripts, tax account information, W-2 information, 1099 information, verification of nonfiling, and records of account. Automated transcript request. You can quickly request transcripts by using our automated self-help service tools. Please visit us at IRS. gov and click on “Get a Tax Transcript...” or call 1-800-908-9946. Where to file. Attach payment and mail Form 4506 to the address below for the state you lived in, or the state your business was in, when that return was filed. There are two address charts: one for individual returns (Form 1040 series) and one for all other returns. If you are requesting a return for more than one year or period and the chart below shows two different addresses, send your request to the address based on the address of your most recent retum, Chart for individual returns (Form 1040 series) i ee filed an Mail to: ‘Alabama, Kentucky, Louisiana, Mississippi, Tennessee, Texas, a foreign country, American Samoa, Puerto Rico, Guam, the Commonwealth of the Northern Mariana Islands, the U.S. Virgin Islands, or AP.O. or F.P.O. address Intemal Revenue Service RAIVS Team Stop 6716 AUSC. Austin, TX 73301 ‘Alaska, Arizona, Arkansas, California, Colorado, Hawaii, Idaho, llinois, indiana, lowa, Kansas, Michigan, Minnesota, Montana, Nebraska, Nevada, New Mexico, North Dakota, ‘Oklahoma, Oregon, South Dakota, Utah, Washington, Wisconsin, Wyoming Intemal Revenue Service RAIVS Team Stop 37106 Fresno, CA 93888 Connecticut, Delaware, District of Columbia, Florida, Georgia, Maine, Maryland, Intemal Revenue Service Massachusetts, RAIVS Team Missouri, New ‘Stop 6705 P-6 Hampshire, New Jersey, ‘ New York, North eee Carolina, Ohio, Pennsylvania, Rhode Island, South Carolina, Vermont, Virginia, West Virginia Chart for all other returns It you lived in or your business was Mail to: Alabama, Alaska, Arizona, Arkansas, California, Colorado, Florida, Hawaii, Idaho, lowa, Kansas, Louisiana, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Mexico, North Dakota, Oklahoma, Oregon, South Dakota, Texas, Utah, Washington, Wyoming, a foreign country, American ‘Samoa, Puerto Rico, Guam, the Commonwealth of the Northern Mariana Islands, the U.S. Virgin Islands, or A.P.O. or F.P.O. address Internal Revenue Service RAIVS Team P.O. Box 9941 Mail Stop 6734 Ogden, UT 84409 Connecticut, Delaware, District of Columbia, Georgia, Illinois, Indiana, Kentucky, Maine, Maryland, Massachusetts, Internal Revenue Service Michigan, New RAIVS Team, Hampshire, New Jersey, P.O. Box 146500 New York, North step 2800 F Carolina, Ohio, Pennsylvania, Rhode Island, South Carolina, Tennessee, Vermont, Viginia, West ia, Wisconsin inati, OH 45250 Specific Instructions Line 1b. Enter your employer identification number (EIN) if you are requesting a copy of a business retum. Otherwise, enter the first social security number (SSN) or your individual taxpayer identification number (ITIN) shown on the return. For ‘example, if you are requesting Form 1040 that includes Schedule G (Form 1040), enter your SSN. Line 3, Enter your current address. If you use a P.O. box, please include it on this line 3. Line 4. Enter the address shown on the last return filed if different from the address entered on line 3. Note: If the addresses on lines 3 and 4 are different and you have not changed your address with the IRS, file Form 8822, Change of Address. For a business address, file Form 8822-B, Change of Address or Responsible Party — Business. ‘Signature and date. Form 4506 must be signed and dated by the taxpayer listed on line 1a or 2a. The IRS must receive Form 4506 within 120 days of the date signed by the taxpayer or it will be rejected. Ensure that all applicable lines are completed before signing. You must check the box in the signature area to acknowledge you have the authority to sign and request the information The form will not be processed and returned to you if the box is unchecked Individuals Copies of jointly filed tax returns may be furnished to either spouse. Only one signature is required. Sign Form 4506 exactly as your name appeared on the original return. If you changed your name, also sign your current name. Corporations Generally, Form 4506 can be signed by: (1) an officer having legal authority to bind the corporation, (2) any person designated by the board of directors or other governing body, or (3) any officer or employee on written request by any principal officer and attested to by the secretary or other officer. A bona fide shareholder of record owning 1 percent or more of the outstanding stock of the corporation may submit a Form 4506 but must provide documentation to support the requester's right to receive the information Partnerships Generally, Form 4506 can be signed by any person who was a member of the partnership during any part of the tax period requested on line 7. All others See section 6103(e) if the taxpayer has died, is insolvent, is a dissolved corporation, or if @ trustee, guardian, executor, receiver, or administrator is acting for the taxpayer. Note: If you are Heir at law, Next of kin, or Beneficiary you must be able to establish a material interest in the estate or trust. Documentation. For entities other than individuals, you must attach the authorization document. For example, this could be the letter from the principal officer authorizing an employee of the corporation or the letters testamentary authorizing an individual to act for an estate. Signature by a representative. A representative can sign Form 4506 for a taxpayer ony if this authority has been specifically delegated to the representative on Form 2848, line 5. Form 2848 showing the delegation must be attached to Form 506. Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to establish your right to gain access to the requested return(s) under the Internal Revenue Code. We need this information to properly identify the return(s) and respond to your request. If you request a copy of a tax retum, sections 6103 and 6109 require you to provide this information, including your SSN or EIN, to process your request. If you do not provide this. information, we may not be able to process your request. Providing false or fraudulent information may subject you to penalties, Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation, and cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in admi their tax laws. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration, of any Internal Revenue law. Generally, tax returns, and return information are confidential, as required by section 6103. The time needed to complete and file Form 4508 will vary depending on individual circumstances. The estimated average time is: Learning about the law or the form, 10 min.; Preparing the form, 16 min.; and Copying, assembling, and sending the form to the IRS, 20 min. Ifyou have comments concerning the accuracy of these time estimates or suggestions for making Form 4506 simpler, we would be happy to hear from you. You can write to: Internal Revenue Service Tax Forms and Publications Division 1111 Constitution Ave. NW, IR-6526 Washington, DC 20224, Do not send the form to this address. Instead, see Where to file on this page.rom 4506T-EZ| Short orm Request for Individual Tax Return Transcript (July 2017) OMB No. 1545-2154 > Request may not be processed if the form is incomplete or illegible. Department of the Treasury 7 7 Internal Revenue Service > For more information about Form 4506T-EZ, visit www irs gov/form4506tez. Tip. Use Form 4506T-EZ to order a 1040 series tax return transcript free of charge, or you can quickly request transcripts by using our automated self-help service tools. Please visit us at IRS.gov and click on “Get Transcript of Your Tax Records” under “Tools” or call 1-800-908-9946. a Name shown on tax return. If a joint return, enter the name shown first. 1b Fir social security number or individual taxpayer lentification number on tax return 2a If ajoint return, enter spouse’s name shown on tax return. 2b Second social security number or indivi taxpayer identification number if j 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 transcript is to be mailed to a third party (such as a mortgage company), enter the third party's name, address, and telephone number. The IRS has no control over what the third party does with the tax information. Third party name Telephone number Jeffrey A. Mowers Esq. c/o Lewis Brisbois Bisqaard Smith LLP 954 728 1280 ‘Address (including apt., room, or suite no), city, state, and ZIP code 110 S.E. 6th St. Suite 2600 Fort Lauderdale FL 33301 Caution. If the tax transcript is being mailed to a third party, ensure that you have filled in line 6 before signing. Sign and date the form once you have filled in this line. Completing this step helps to protect your privacy. Once the IRS discloses your IRS transcript to the third party listed on line 5, the IRS has no control over what the third party does with the information. If you would like to limit the third party s authority to disclose your transcript information, you can specify this limitation in your written agreement with the third party. 6 Years) requested. Enter the year(s) of the return transcript you are requesting (for example, “2008”). Most requests will be processed within 10 business days. 2017 2018 2019 Note. /f the IRS is unable to locate a return that matches the taxpayer identity information provided above or if IRS records indicate that the return has not been filed the IRS will notify you or the third party that it was unable to locate a return or that a return was not filed whichever is applicable. Caution. Do not sign this form unless all applicable lines have been completed. Signature of taxpayer s). | declare that | am the taxpayer whose name is shown on either line 1a or 2a. If the request applies to a joint return, either ‘spouse must sign. Note: This form must be received by IRS within 120 days of the signature date. O 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-T. See instructions. Phone number of taxpayer ‘on line 1a or 2a Sign » ‘Signature (see instructions) Date Here U Spouse’s signature Date For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 54185S Form 4506T-EZ (Rev. 7-2017)Form 4506T-EZ (Rev. 7-2017) Page 2 Section references are to the Internal Revenue Code unless otherwise noted. Future Developments For the latest information about developments related to Form 4506T-EZ, such as legislation enacted after it was published, go to www.irs.gov/form4s06tez. Caution. Do not sign this form unless all applicable lines have been completed. Purpose of form. Individuals can use Form 4506T-EZ to request a tax return transcript for the current and the prior three years that includes most lines of the original tax return. The tax return transcript will not show payments, penalty assessments, or adjustments made to the originally filed return. You can also designate (on line 5) a third party (such as a mortgage company) to receive a transcript. Form 4506T-EZ cannot be used by taxpayers who file Form 1040 based ona tax year beginning in one calendar year and ending in the following year (fiscal tax year). Taxpayers using a fiscal tax year must file Form 4506-T, Request for Transcript of Tax Return, to request a return transcript. Use Form 4506-T to request tax return transcripts, tax account information, W-2 information, 1099 information, verification of non-filing, and record of account. Automated transcript request. You can quickly request transcripts by using our automated self-help service tools. Please visit us at IRS.gov and click on “Get Transcript of Your Tax Records” under “Tools” or call 1-800-908-9946. Where to file. Mail or fax Form 4506T-EZ to the address below for the state you lived in when the return was filed. If you are requesting more than one transcript or other product and the chart below shows two different addresses, send your request to the address based on the address of your most recent return. If you filed an Mail or fax to the individual return “Internal Revenue and lived in: Service” at: Alabama, Kentucky, Louisiana, Mississippi, Tennessee, Texas, a foreign country, 7 RAIVS Team American Samoa, Stop 6716 AUSC Puerto Rico, Guam, the Commonwealth of the Northern Mariana Islands, the U.S. Virgin Islands, or A-P.O. or F.P.O. address Alaska, Arizona, Arkansas, California, Colorado, Hawaii, Austin, TX 73301 855-587-9604 Idaho, Illinois, Indiana, lowa, Kansas, Michigan, RAIVS Team Minnesota, Montana, | Stop 37106 Nebraska, Nevada, New Mexico, North Dakota, Oklahoma, Oregon, South Dakota, Utah, Washington, Wisconsin, Wyoming Connecticut, Delaware, District of Columbia, Florida, Georgia, Maine, Fresno, CA 93888 (855) 800-8105 Maryland, Massachusetts, preload lassach Stop 6705 P-6 Missouri, New ee oe Hampshire, New eames Jersey, New York, North Carolina, Ohio, Pennsylvania, Rhode Island, South Carolina, Vermont, Virginia, West Virginia Line 1b. Enter your employer identification number (EIN) if your request relates to a business return. Otherwise, enter the first social security number (SSN) or your individual taxpayer identification number (|TIN) shown on the return. For example, if you are requesting Form 1040 that includes Schedule C (Form 1040), enter your SSN. Line 3. Enter your current address. If you use aP.O. box, include it on this line. Line 4. Enter the address shown on the last return filed if different from the address entered on line 3. Note. If the address on lines 3 and 4 are different and you have not changed your address with the IRS, file Form 8822, Change of Address. Signature and date. Form 4506T-EZ must be signed and dated by the taxpayer listed on line 1a or 2a. The IRS must receive Form 4506T-EZ within 120 days of the date signed by the taxpayer or it will be rejected. Ensure that all applicable lines are completed before signing. You must check the box in the signature area to acknowledge you have the authority to sign and request the information. The form will not be processed and returned to you if the box is unchecked 855-821-0094 Transcripts of jointly filed tax returns may be furnished to either spouse. Only one signature is required. Sign Form 4506T-EZ exactly as your name appeared on the original return. If you changed your name, also sign your current name. Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to establish your right to gain access to the requested tax information under the Internal Revenue Code. We need this information to properly identity the tax information and respond to your request. If you request a transcript, sections 6103 and 6109 require you to provide this information, including your SSN. If you do not provide this information, we may not be able to process your request. Providing false or fraudulent information may subject you to penalties. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation, and cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by section 6103. The time needed to complete and file Form 4506T-EZ will vary depending on individual circumstances. The estimated average time is: Learning about the law or the form, 9 min.; Preparing the form, 18 min.; and Copying, assembling, and sending the form to the IRS, 20 min. If you have comments concerning the accuracy of these time estimates or suggestions for making Form 4506T-EZ simpler, we would be happy to hear from you. You can write to: Internal Revenue Service Tax Forms and Publications Division 1111 Constitution Ave. NW, IR-6526 Washington, DC 20224 Do not send the form to this address. Instead, see Where to file on this page.HIPAA AUTHORIZATION FORM I hereby authorize use of disclosure of protected health information about me as describe below. 1. The following specific person or class of persons or facility is authorized to make the requested use of disclosure: Hospitals, all treating practitioners or other healthcare providers, physical therapy, x-rays, prescriptions/medications. 2. The following person or class of persons may receive disclosure of protected health information about me: The attorneys representing Defendants in the case of JUSTINO VEGA PENA and JUSTIN WILLIE VEGA v. SONY JOSEPH and HL UNIVERSAL, INC., a Florida Profit Corporation Case No.: 50-2020-CA-007743 (AN) His/Her name is: Jeffrey A. Mowers, Attorney for Defendants His/Her address is:_110 SE 6 Street, Suite 2600, Fort Lauderdale, Florida 33301 3. The specific information that should be disclosed is: All medical and billing records 4. | understand that the information used or disclosed may be subject to re- disclosure by counsel for Defendants for purposes of defending the lawsuit. 5. | understand that this authorization is voluntary. While | understand that | have the right to revoke this authorization in writing submitted to counsel for Defendants, | agree that any revocation may impact my ability to further prosecute the pending litigation should a court so order. Justino Vega Pena Date Date of Birth 4831-4229-1284.1 4826-5276-9545.1A: if ED) FIRST COAST SERVICE OPTIONS INC. A GIS Contracien hirenvevinny & CARRIER MEDICARE Cnas/ CRS er sarc EDC Be, Freedom of Information AUTHORIZATION TO SHARE “PROTECTED HEALTH INFORM. ATION® PURPOSE: The purpose of this authorization is to Permit Medicare to release to a third Party, SuCh as someone other than the benesiciary, my Protected Health infonnat! ‘on, specific to my Medicare records and/or claim information, SECTION: Please provide the following information regarding the beneficiary whose Protected Health Infozmation is to be disclosed, (Please Print) Name: Address: Telephone: Daytime Evening Date of Birth: Medicare Number: oe SSeS SECTION Hi: J hereby authorize Medicare to share the following Protected Health Information concerning me: CJ Identifying information (e.g. name, address, age, gender); Health care Coverage information; Claim information for Date(s) to : Past, present and future claim information; SECTION HL: Please identify the Person(s) or orgenization(s) with whom Medicare may share your Protected Health Information: Name; — ~. SECRECY Address: Jeffrey A.M. aire ——— LEWIS F GAARD & SMITH, LLP Oe te 2600 Fort ieuderdate, FT. 33301 ——_! Sa aeSECTION iV: Please enter a date OR select an event, upon which you want this authorization to expire, ‘This authorization will expire: Hh, eb i. Month Day Year OR: When my Medicare coverage ends SECTION V: . You have the right to take back (“ Tevoke”) your authorization at any time, in writing, except to the extent that Medicare has already ‘acted based on your permission: To revoke your authorization, sené a written request to: First Coast Service Options, Inc, Medicare Freedom of Information Coordinator PO BOX 2078 1 Jacksonville, Florida 32231-0048 4 T understand refusal to authorize disclosure of my Protected Health Information will have no effect on my enrollment, eligibility, for benefits, or the amount Medizare pays for the health services [ receive, Your Protected Health Information that yau authorize Medicare to disclose may be subject to redisciesure and no longer protected by law. A photocopy of this authorization is as valid as the original SIGNATURE: Beneficiary Signature; Date: Ifsomeone else is signing this authorization form on behalf of the beneficiary, pleasé provide the following information: , Legal Representative*: Date Signed: __ Relationship to the beneficiary: * Documentation must be provided to support your stat us as a guardian or ether legal representative * Please complete the entire form and return with a written request to: First Coast Service Options, Inc Atin: Medicare Freedom of Information PO BOX 2078 Jacksonville Florida 32231-0048FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, RICK SCOTT dj: ELIZABETH DUDEK GOVERNOR Better Health Care for all Floridians SECRETARY Authorization for the Use and Disclosure of Protected Health Information Federal law states that we cannot share an individual's health information without the individual’s permission, except in certain situations. By signing this form, you are giving us permission to share th formation you indicate below. If you decide later that you do not want us to share this information any more, you can revoke this authorization at any time in writing or sign the REVOCATION SECTION on the back of this form and return it to Xerox Recovery Services. This form must be completed and signed by the Medicaid recipient or by an in ual who has the authority to act on the Medicaid recipient's behalf (parent of a minor, legal guardian, trustee, power of attorney, personal representative of the estate, grantor of an annuity). 1. 3. 4. PLEASE COMPLETE THE FOLLOWING SECTIONS Personal Information: Medicaid Recipient's Name, Date of Birth, Medicaid ID Number. Social Security Number, | give permission to the Agency for Health Care Administration (AHCA) and its contract representatives to share the health information listed below with the following: ervey BROS BARD ene 110 S.E. 6th Street, Suite 2600 Name of the Law Firm or Law Office_Fort Lauderdale, FL 33301 Name of the Insurance Company, Other, Indicate the purpose for which the disclosure is to be made: To substantiate Medicaid’s lien relating to a lawsuit To substantiate Medicaid’s claim against the estate or against a trust account or annuity Other Indicate the information that you want to be disclosed, related to the following (check one): __The Medicaid lien relating to the injury or negligence charges, for the period beginning with the date of incident. __Medicaid’s claim against the estate. __The amount that is due Medicaid from the trust account, [Please send a copy of the trust agreement]. __The amount that is due Medicaid from the annuity account, [Please send a copy of the annuity agreement]. __ Other, [Please be specific}. Enter the specific date that you want this authorization to expire: (i.e., one year from date of release). (If you do not enter a date, this authorization will expire in five years.) | understand that the information described above may be redisclosed by the p