Party Discovery: DUME, JEAN vs. BURGIEL, JONATHAN, SRet al.

On August 11, 2017 a Party Discovery was filed involving a dispute between Jean Dume, and Jonathan Burgiel Jr, Jonathan Burgiel Sr, in the District Court of Orange County.

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Filing # 63862055 E-Filed 11/07/2017 11:48:41 AM

IN THE CIRCUIT COURT OF THE NINTH
JUDICIAL CIRCUIT IN AND FOR
ORANGE COUNTY, FLORIDA

CASE NO.: 2017-CA-007422-0
JEAN DUME,

Plaintiffs,

VS.

JONATHAN BURGIEL,

Defendants.

DEFENDANT'S REQUEST TO PRODUCE TO PLAINTIFF

Pursuant to Rule 1..350 of the Florida Rules of Civil Procedure, the undersigned counsel

requests the Plaintiff, Jean Durne, to produce and permit for inspection, copying, testing, sampling,

measuring, surveying, photographing, or otherwise examining the following:
1. If you are making a claim for lost wages or reduction in future earning capacity, please

provide copies of any evidence of income for the two years prior to the year of the accident and during the

year of the accident.

2. If unable to provide documents responsive to Request No. 1, please produce signed

authorizations utilizingthe fortns attached hereto as Composite Exhibit "A", allowing Defendant to obtain

copies of your income tax returns from the Internal Revenue Service (Request for Copy of Tax Return, Form

4506)), Plaintiff s earnings record from (Request for Earnings, Form SSA-

7050-F4 (1-2004)), and disability benefits information from (Consent for Release of

Information, Form (5-2007)).

3. Copies of any applications for eniployment made by the Plaintiff three (3) years prior to the
accident or since the accident until this Request to Produce is due.

4. Copy of the registration and title to the motor vehicle which was involved in the accident.

5. A copy of Plaintiff s driver's license.
6. All repair estimates for vehicle damage to any vehicle involved in the accident or any

damage to property as a result of the accident.

7. All photographs, slides,movie films, and video tapes taken of any of the vehicles involved

in the accident.

8. Any and all photographs, graphs, charts and other documentary evidence of the scene of the

accident or the parties involved or pertaining to the alleged accident, occurrence or issues in thiscause.

9. Any and all statements obtained by you, your attorney, your insurance carrier or anyone

acting on your behalf from any person regarding any of the events or happenings referred to in the pleadings.

10. Any and all insurance policies providing benefits or coverage to the Plaintiff for any claim to

injury or damage from the alleged subject incident or occurrence.

11. Any and all applications and/or claims submitted by the Plaintiff or on his/her behalf for any

payments and/or benefits of any type to pay the damages described in the Complaint including but not limited

to payments for medical expenses, funeral expenses, lost wages, loss of earning capacity and any period of

disability following the accident, including but not limited to all claims for personal injury protection

benefits, medical payments benefits, liabilityinsurance benefits, uninsured motorist benefits, and allother

claims to some person, business, business organization, insurance carrier or governmental entity to pay the

same items of expense claimed by the Plaintiff in this lawsuit.
12. All medical, surgical, x-ray, dental, rehabilitative, ambulance, hospital, nursing care,

physical therapy, or massage treatment reports, records, and statements for services concerning the treatment,

examination and/or evaluation of the Plaintiff at any time, both before and after the accident set forth in the

Complaint, for any condition which the Plaintiff claims was caused and/or aggravated by the incident set

forth in the Complaint. Be sure to include itemized statements indicating the dates service was rendered by

the provider, the amount charged and the amount paid to date.

13. Copies of any and all medical records, hospital records, emergency room records and

records from any health care provider pertaining to the treatment of Plaintiff(s) for any reason in the five (5)

years prior to the within incident.
14. Copies of any and all medical records, hospital records, emergency room records and

records from any health care provider pertaining to the treatment of Plaintiff(s)for any reason since the

within incident.

15. Copies of any and all medical bills and/or statements for services rendered, paid or unpaid,

as aresult of the within incident, including any bills for drugs or other related expenses.

16. Copies of any and all bills, statements or receipts relating to any non-medical expenses claimed

as damages in this lawsuit which have not been produced in response to any of the preceding paragraphs.

17. Any and all x-rays or MRI films or CT scans taken of the Plaintiff as aresult of the subject

accident.

18. Any and all x-rays or MRI films or CT scans in the Plaintiffs possession.

19. For any records not in your possession at this time, please produce a signed authorization(s)
in the form attached to this pleading as Exhibit "Er, authorizing the release of the medical records to our

office in order to evaluate this claim.

20. Copy of the accident report.

21. Copy of the PIP payout sheet and/or declarations page regarding any personal injuiy

protection benefits or med pay benefits.
22. Copies of any and all letters of protection from any and all medical providers.
23. Copies of any and allcorrespondence, letters, or other documentation provided to any

medical providers.

24. All documents, papers orevidence to be introduced at trial.
25. All expert reports from any experts who will testify at trial.
26. Please provide any and all cell and/or mobile phone carrier records and/or documentation

including, but not limited to, billing statement(s) for Februaiy 11, 2015 that were owned and/or used by
the Plaintiff on February 11, 2015.
27. A full and complete copy print including of Plaintiff, and any and all known and

unknown aliases, but not limited to, photographs, comments, messages, tweets, replies, and emails from

social media accounts including, but not limited to, Facebook, MySpace, Linkedln, MyLife, Comfibook,
Corporationwiki, Classmates, Twitter, Instragrarn and Pininterest from February 11, 2015 until this

Request to Produce is due.
28. Please produce any computer recorded information from the vehicle, including any and all

data obtained, recorded or received by any computer recording device in the vehicle, including the original
recording device itself,such as "black box", together with any additional data retrieved from any computer

system aboard the vehicle that would relate any facts about the subject accident, including but not limited to

data and time of crash, speed, seat belt use, air-bag deployment, activation of brakes, lights, or other functions
and features of the vehicle, including Delta-V.

It isrequested that the above documents and materials shall be produced from thirty days
within the date of service, at the office of Law Office of Deborah N. Hartwell at the address shown

below.

In support of this Request to Produce, it is shown that the documents and/or materials being

here requested are believed to be in the possession, custody, or control of the party to whom this

Request is directed. The information sought by this Request is relevant to the subject matter of this

action and cannot otherwise be obtained without undue hardship. In the event that all or part of the

documents and/or material requested are not in the possession or control of the above addressee,
then the undersigned counsel further request the identity and location of all persons having such

possession and control. This Request is made in good faith and for the purposes herein expressed.
CERTIFICATE OF SERVICE

I HEREBY CERTIFXbat a trueRld,corirect copy ofthe foregoing has been furnished by
Electronic Mail on this the IP day of /V0Vakitr, 2017 to the following designated service
email address(es): Jeremy L. Hogan, Esq., Hogan & Hogan, P.A., jhogan@hoganlegal.com,
scunningham@hoganlegal.com.

Law Office of Debor.. Hartwell
/,./A,Tel J. Lamarre
Angel J. Lamarre, Esqui e

(Employees of the GEICO General Insurance
Company)
Florida Bar No.: 0011591
1000 Legion Place, Suite 850
Orlando, FL 32801
Phone: (407) 648-8236
Facsimile: (407) 648-2650
Attorney for Defendant(s): Jonathan Burgiel
Service Email: orlandogeico@geico.com
6 6 TJT1.1 !t• 5)
!A, 1
WIN,
Administration Form Approved
Consent for Release of Information OMB No. 0960-0566

You must complete all required fields. We will not honor your request unless all required fields are completed. (*signifies a
required field).
TO: Administration

*My Full Name *My Date of Birth *My
(MM/DD/YYYY)
I authorize the Administration to release information or records about me to:
*NAME OF PERSON OR ORGANIZATION: *ADDRESS OF PERSON OR ORGANIZATION:

*I want this information released because:
We may charge a fee to release information for non-program purposes.

*Please release the following inforrnation selected from the list below:
You must specify the records you are requesting by checking at least one box. We will not honor a request for "any and all
record& or "my entire file." Also,we willnot disclose records unless you include the applicable date ranges where requested.

1. n
2. j Current monthly benefit amount
3. Current monthly Supplemental Security Income payment amount
to date
4. ID My benefit or payment amounts from date
entitlement from date to date
5. 111 My
6. Ej Medical records from my claims folder(s) from date to date

lf you want us to release a minor child's medical records, do not use this form. instead, contact your local
office.
7. Complete medical records from my claims folder(s)
8. 1=1 Other record(s) from my file (you must specify the records you are requesting, e.g., doctor report, application,
determination or questionnaire)

of a minor, or
I am the individual, to whom the requested information or record applies, or the parent or legal guardian
adult. ideclare under penalty of perjury (28 CFR § 16.41(d)(2004)) that I have
the legal guardian of a legally incompetent
and it istrue and correct to the
examined all the information on this form, and any accompanying statements or forms,
I understand that anyone who knowingly or willfully seeks or obtain access to records about
best of my knowledge.
another person under false pretenses is punishable by a fine of up to $6,000. I also understand that I must pay all

applicable fees for requesting information for a non-program-related purpose.
*Date:
*Signature:
*Address:

Relationship (if not the subject of the record): *Daytime Phone:
•

Witnesses must sign this form ONLY if the above signature is by mark (X). lf signed by mark (X), two witnesses to the signing
and theirfulladdresses. Please print the signee's name next to the mark (X) on the
who know the signee must sign below provide
signature line above.
1.Signature of witness I 2.Signature of witness

Address(Number and street,City,State, and Zip Code) 1Address(Number and street,City,State, and Zip Code)
Form (07-2013) EF (07-2013)
Form SSA-7050-F4 (10-2016) UF Page 2 of 4

REQUEST FOR EARNINGS INFORMATION
1. Provide your name as it appears on your most recent card or the name of the individual whose
earnings you are requesting.
First Name: Middle Initial:

Last !lame:

Number One
(SSN)

Date of Birth: Date of Death:

Other Name(s) Used
Maiden
(Include Name)
2. What kind of earnings information do you need? (Choose ONE of the following types of earnings
orSSA must return thls request.)

Year(s) Requested: to
Itemized Statement of Earnings $115

(Includes the names and addresses of employers) Year(s) Requested: to
If you check this box, tell
uswhy you need this information below.

1-1 Check this box if you want the eamings information
I-1 CERTIFIED for an additional $33.00 fee.

n Certified Yearly Totals of Earnings $33 Year(s) Requested: to

(Does not include the names and addresses of employers)
Year(s) Requested: to
Yearly earnings totals are FREE to the public if you do not
To obtain FREE yearly totals of earnings,
require certification.
visit
ourwebsite at www.ssaxiov/mvaccount.
3. If you would like this information sent to someone else, please fill in the information
below.

I authorize the Administration to release the earnings information to:

Name

Address I State

l ZIPCode
City
4. Iam the individual to whom the record pertains (or a person authorized to sign on behalf of that individual).I
understand that any false representation to knowingly and willfully obtain information from records is
punishable by a fine of not more than $5,000 or one year in prison.
Printed Name of individual Legal Guardian days from the date signed
ssA must receive this form within 120
Signature AND or

Date:

Relationship (if applicable, you must attach proof) Daytime Phone:

Address State

ZIP Code
City
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 (X) on the signature
line above.
1. Signature of Witness 12. Signature of Witness

Address (Number and Sheet, Cily, State and ZIP Code) 'Address (Number and Street,
City, State and ZIP Code)
of Tax Return
Form 45O l Request for Copy
orkile No. 1545-0429
•
applicable lines have been completed.
Do not sign this form unless all
(Rev. September 2015) •,

10. Request may be rejected if the form is incomplete or illegible.
Department of the Treasury 11.- For more information about Form 4506, visit wwwirs.govIform4506.
Internal Revenue Service

by a paid preparer, they
Tip. You may be able to get your tax return or return inforrnation from other sources. If you had your tax return completed
for many returns free of charge. The transcript
shouid be able to provide you a copy of the retum. The IRS can provide a Tax Return Transcript
as a mortgage company)
third party (such
provides most of the line entries from the original tax return and usually contains the Information that a
our automated self-help service
requires. See Form 4506-T, Request for Transcript of Tax Return, or you can quickly request transcripts by using
tools. Please visit
us at1RS.gov and click on "Get a Tax Transcript..." or call 1-800-908-9946.
1b First on taxreturn,
1a Name shown on ajoint return, enter the name shown first.
tax return. If
individual taxpayer identification number, or
employer identification number (see instructions)

tax return. 2b Second orindividual
2a joint return, enter spouse's name shown
If a on
taxpayer identification number if joint tax return

3 Current name, address and ZIP code
(including apt., room, or suite no.), city, state,

4 Previous address shownon (see Instructions)
the last return filed if different from tine 3

5 a third party (such
If the tax return Is to be mailed to as amortgage company), enter the third party's name, address, and telephone number.

6 and 7 before signing. Sign and date the form once you
Caution: If the tax return is being mailed to a third party, ensure that you have filled in lines
thesesteps helps
have filled in these lines. Completing to protect
yourprivacy.Once theIRSdiscloses your tax return to the third party listed on line
third does withthe If
information. would to limit the third party's authority to disclose your return
like
party
5, the IRS has no control over what the you
information, you can specify this limitation in your written agreement with the third party.
Form 1040, 1120, 941, etc.and allattachments as submitted
originally to the IRS, includingForm(s)W-2,
6 Tax returnrequested.
schedules,or amended returns. Copies of Forms 1040, 1040A,
and 1040EZ are generally available for 7 years from filing before they are
return number. If you need more than one
destroyed by law. Other returns may be available for a longer period of time. Enter only one
type of return, you must complete another Form 4506. 11..
Note: If the copies must be certifieci for court or adrninistrative proceedings, check here jjJ
format. If you are requesting more than
T Year or period requested. Enter the ending date of the year or period, using the mm/dd/yyyy
eight years or periods, you must attach another Form 4506.

8 Fee. There Is be included with your request or it will
a $50 fee for each return requested. Full payment must
Make check order payableto "United States Treasury." Enter your SSN, ITIN,
be rejected. your ormoney
or EIN and "Form 4606 request" on your check or money order.
50.00
a Cost for each return
b Number of returns requested on line 7
c Total cost. Multiply line 8a by line 8b
9
third party listed on line 5, check here
If we cannot find the tax return, we will refund the fee. If the refund should go to the
EiI
lineshave
Caution: Do not sign this form unless all applicable been completed.
name is shown on line la or 2a, or a person authorized to obtain the tax return
Signature of taxpayer(s). I declare that I am either the taxpayer whose
must sign. If signed by a corporate officer, 1 percent or more shareholder, partner,
requested. If the request applies to a joint return, at least one spouse
trustee, or party other than the taxpayer, I certify that I have the authority to
managing member, guardian, tax matters partner, executor, reoeiver, administrator,
to a third party, this form must be received within 120 days of the signature date,
execute Form 4506 on behalf of the taxpayer. Note: For tax returns being sent
so reading.
E Signatory attests that he/she has read the attestation clause and upon Phone number of taxpayer on line
declares that he/she has the authority to signthe Form 4506. See instructions.
I la or 2a

Date
Signature (see Instructions)
•

Sign
Here
Pr (if line la above Is a corporation, partnership, estate, or trust)
Title

Date
r Spouse's signature
Gat. No. 41721E Form4506 (Rev. 9-2015)
For Privacy Act andPaperwork Reduction Act Notice, see page 2.
REQUEST FOR EARNINGS INFORMATION

1. earnings information?
Frorn whose record do you need the

Print the Name, Number (SSN), and date of birth below.

Name

Other Name(s) Used Date of Birth

(Include Maiden Name) (Mo/Day/Yr)

2. What kind of information do you need?

0 Detailed Earnings Information For the period(s)/year(s):
(If you check this block, tell us below
why you need this information.)

El Certified Total Earnings For Each Year. For the year(s):

(Check this box only if you want the information
Otherwise, call 1-800-772-1213 to
certified.
requestForm SSA-7004, Request for Earnings
and Benefit Estimate Statement)

3. information, enter the amount due
If you owe us a fee for this detailed earnings
A. $
using the chart on page 3

Do you want us tocertify the information? CI Yes No

If yes, enter $15.00 B.

ADD the amounts on lines A and B, and
Enter the TOTA1, amount
C. $

• You can pay by CREDIT CARD by completing and returning the form on page 4, or
• Send your CHECK or MONEY ORDER for the amount on line C with the request
And make check or money order payable to "Social Security Administratioe
• DO NOT SEND CASH.

4. Iarnthe individual to whom the record pertains (or a person who is authorized to sign on behalf of that
I understand that any false representation to knowingly and willfully obtain information from
individual).
records is punishable by a fine of not more than $5,000 or one year in prison.

SIGN your name here
> Date
(Do not print)

Daytime Phone Number
(Area Code) (Telephone Number)

5. (Please print)
Tell us where you want the information sent.

Name Address
•

City, State & Zip Code

6. ivIail Completed Form(s) To: Exception: FedEx) to mail form(s) use:
If using private contractor (e.g.,

Administration Administration
Division of Earnings Record Operations Division of Earnings Record Operations
P.O. Box 33003 300N. Greene Street
Baltimore Maryland 21290-3003 Baltimore Maryland 21290-0300
EF
Form SSA-7050-F4 (7-2001) (05-2002)
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AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

TO:

I hereby authorize you to release to Law Office of Deborah N. Hartwell, 1000 Legion Place,
Suite 850, Orlando, FL 32801: All records relating to medical treatment, and testing, care or

examination of Jean Dume, including but not limited to, emergency room records, reports, x-ray
films, x-ray reports, bills, notes, progress reports, evaluations, memoranda, patient information,
and/or any other documents of any nature whatsoever pertaining tothe care and treatment of Jean
Dume, from the date of inception of your records to the present.

•

Date of Birth:

In compliance with the new HIPAA rules, I certify that I have been provided with written
notice of the intent to obtain the above-described medical records and that the notice provided
sufficient information about the litigation or proceeding to permit me to raise any objection to the

production of the requested documents and that I waive any objection I may have to the production
of the requested documents. I acknowledge that the purpose of the Authorization is to permit
Defendant(s) in a motor vehicle accident lawsuit to obtain my records for use in the litigation. I
acknowledge that the records obtained by this Authorization are to be used for the purposes of the
said litigation only. By using this Authorization to obtain my niedical records, the person to whom
the records are to be disclosed is restficted to redisclosing the records only to the extent required for
the litigation and evaluation of my claims.

Treatment, payment, enrollment or eligibility for benefits may not be conditioned on

obtaining the Authorization.
I acknowledge that I may revoke this Authorization in writing at any time. Unless sooner

revoked, this Authorization will expire on at the end of this litigation..

Jean Dume

Date

Case Info

Judge

Kevin B. Weiss Track Judge’s New Case

Case No.

(Subscribe to View)

Document Filed Date

November 07, 2017

Case Filing Date

August 11, 2017

County

Status

Closed

Parties

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