Roger Seehafer v. Weyerhaeuser Company, et al
Filing
117
ORDER Establishing Records Collection Protocol and Procedures Relating to the Authorization for Release of Medical and Other Records. Signed by Magistrate Judge Stephen L. Crocker on 3/20/2015. (arw)
UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF WISCONSIN
MADISON DIVISION .
This document relates to:
Boyer v. Weyerhaeuser Company, et al.
Masephol v. Weyerhaeuser Company, et al.
Pecher v. Weyerhaeuser Company, et al. ·
Prust v. Weyerhaeuser Company, et al.
Seehafer v. Weyerhaeuser Company, et al.
Sydow v. Weyerhaeuser Company, et al.
CASE NO. 14'-cv-286
CASE NO. 14-cv-186
CASE NO. 14-cv-147
CASE N0.14-cv-143
CASE NO. 14-cv-161
CASE NO. 14-cv-219
ORDER ESTABLISHING A RECORDS COLLECTION PROTOCOL AND
PROCEDURES RELATING TO THE AUTHORIZATION FOR.RELEASE OF
MEDICAL, HEALTHCARE, PHARMACY, BANKRUPTCY TRUSTS AND OTHER
RECORDS
AND NOW, this the ·20 ~ay o~ rv+~H , 2014, after conferring with the parties as to the
protocol for records collection, we have determined that in furtherance of the efficiency and
economy of this litigation it is in the interest of all parties to proceed ·w ith records. collection as
outlined below.
Also before the Court upon the joint application of the parties is a request for an Order ·
aiding in the collection and distribution of records, including medical records, bankruptcy trusts
records and employment records. After consideration of this joint request and finding that such
I
an Order would facilitate the orderly, uniform and cost-effective acquisition of relevant
information and materials for this litigation, IT IS ORDERED as follows:
1) The basis for this Order. Plaintiff is required to turn over all medical evidence in Plaintiff's
possession, custody, or control. In addition to the medical records, plaintiff is required to submit
a Health Insurance Portability and Accountability ("HIPAA")-compliant authorization
to the defendants 8$ soon as possible. Some healthcare providers, pharmacies and other
entities having custody of these records (including, where applicable, employment, military
and Social Security records), however, have refused to release such records unless specific
forms prepared by the particular entity are used. Requiring specific forms prepared by
individual entities causes a delay in the exchange of relevant information in this litigation. In
order to facilitate the timely exchange of medical and other information, the parties have
prepared an Authorization Form that is fully compliant with HIPAA. The Authorization Form
is attached as Exhibit A.
It has also been determined by all parties that there is a need to standardize the authorizations for .
the collection of the bankruptcy trust records. The Authorization Form for the bankruptcy
trusts records is attached as Exhibit B.
In addition, attached as Exhibit C is a Social Security Records Release/Authorization Form.
The purpose of this Order is to provide for a simple, uniform, and cost-effective process for
the collection of records relevant to the case pending before this Court. Time is of the essence
in collecting these records. Accordingly, this Order is issued pursuant to the Court's authority
to. direct and control the coordinated discovery in this litigation pursuant to Fed. R. Civ. P. 16
·
and Fed. R. Civ. P. 26(b).
2) Discovery Affected by this Order. This Order applies to the procurement of information and
materials from entities including, but not limited to, physicians, healthcare providers,
pharmacies1 educational facilities, former and present employers, insurance providers, all
branches of the military and any other federal, state and/or local government agencies. This
Order ·also applies to the procurement of information and materials from bankruptcy trusts
and/or their administrators, and claims processing facilities, or any 3rd party entities
authorized or designated by the bankruptcy trusts for claims processing or document
retention that have access to bankruptcy trust information relating to plaintiff. The Court
anticipates that this will constitute all necessary document production from the trusts but it is
without prejudice to any party's right to seek permission to obtain records from the
i bankruptcy trusts in unexpected circumstances.
· 3) Parties Affected by this Record-Production Protocol This Protocol binds plaintiff and all
defendants in this case. The firm of Forman Perry Watkins Krutz & Tardy, LLP ('~Forman
Perry"), who represents Defendant Weyerhaeuser in this case, shall collect all medical and
other records in this case.
4) Scope ofRecord-Production Protocol The protocol shall be in place for all records
collection from this date forward. Defendants shall not be charged with colle.ction of
additional records, which may be outlined in the definitions section, which were not
previously requested from a provider.
5) Definitions. This protocol shall employ the following definitions:
a) "Medical records" refers to:
i) All records, reports, bills, test results, or other documents concerning the
medical care, treatment, and examination of a patient;
ii) All pathology, that is not necessary for care and treatment, original tissue
blocks, original tissue slides, wet tissue, records, self-histories, histochemical, and
irnmunochemical reports, autopsy reports including but not limited to handwritten
notes and/or drawings associated with the autopsy, test results, other
documents, or electronic information concerning the medical care, treatment, and
examination of the patient, including photomicrographs, millipore filters, written
tissue digestion protocol, or other material related 'in any way to any lung tissue,
asbestos fiber burden analysis or ferruginous body study performed on the
tissues of the patient;
·
iii) Copies of bills or statements of services rendered for such service;
iv) X-ray films, Iv1Rl films, CT films, and all other imaging films involving the
patient.
b) "Social Security Administration records" refers to any information
regarding the person's Social Security records, including but not limited to the
information requested on Federal Form SSA-7050-F4 ("Request for Social Security
Earnings Information")
c) "Military records" refers to any and all information regarding the person's US Military
records, including but not limited to the information requested on Federal Form SFl 80
("Request Pertaining to Military Records")
d) "Union records" refers to union information and records including but not
limited to:
i) Application for membership;
ii) Yearly income including number of hours/days worked per year;
iii) Names and addresses of any and all employers, locations of work sites
including any job and/or work logs;
iv) Any pension related information including documents showing pension
contributions by employers;
.
v) Records of any grievances filed or claims made for work-related injuries;
vi) Records of all claims for health, accident, pension or disability benefits;
vii) All records pertaining to any claim for injuries allegedly during the course of
his/her employment;
viii) All medical reports and records, infirmary records, return to work slips,
medical excuses, and accident reports; and
e) "Authorizations" refers to Exhibit A, B, and C to this Order.
6) Duty To Accept Court-Approved Authorization To Release Medical Records, Employment
Records and Bankruptcy Trust Records and Information. The Authorization Forms
attached to this Order as Exhibits A, B, and C are HIP AA compliant and have been
approved for use in all claims affected by this Order. Accordingly:
a) All physicians, healthcare providers, pharmacies, pharmacy benefits managers
("PBM"), educational facilities, former and present employers, insurance providers, all
branches of the military, any federal, state and/or local government agencies, bankruptcy
trusts or any other entity asked to produce records relating to a plaintiff or employee (all
referred to as "Entities") shall accept the Authorization Form as valid for all claims
affected by this Order;
b) Entities may not request or insist upon different forms or terms different from the
Authorization Form;
c) When signed by a patient or employee and plaintiff in claims affected by this Order,
the Authorization Form shall be relied upon by all Entities to authorize the release of all
records, including all medical records;
d) No facility-specific or different form shall be necessary for production of any records
relating to a current or former patient or employee;
e) A photocopy or .pdf image qf the Authorization Form shall be accepted;
f) No original signatures shall be required oii the Authorization Form for production of
any records relating to a current or former patient or employees;
g) Any Authorization Form dated after January 1, 2014 shall be effective for production
of any records relating to a current or former patient or employee and no differently dated
Authorization shall be necessary or requested by the Entities;
It) Entities may not impose any waiting period for the production of records; and
i) Entities may not condition the release of requested records upon the payment of
unreasonable "processing"' or "handling" fees.
The third party entities in receipt of such release requests shall presume that the Court has
reviewed and deems appropriate the provision outlined above. However, this provision does
not preclude any affected third party from raising any objection that it feels is appropriate.
7) Signature of Plaintiffs Representative. In an effort to obtain records for plaintiff in a timely
fashion, the Court finds it necessary for the efficient procurement of those records to have
specific rules pertaining to the signing of the Authorization Form, attached hereto as Exhibit
A, B, and .C, by representatives of plaintiff. For the sole and limited purpose of obtaining
records associated with a case covered by this Order, plaintiff's counsel may be considered
the representative of plaintiff. All Entities are hereby Ordered to accept an Authorization
signed by plaintiff's counsel without additional documentation required.
'
8) Autltorization for Release ofRecords. Plaintiff's counsel shall .serve all counsel of record
with a copy of the Court-Ordered Authorization for Release of Bankruptcy Trust Information
attached hereto as Exhibit B within a reasonable time period, not to exceed 30 days. The
parties may agree to the service of this Authorization on any party who the defendants may
designate as their counsel for service of bankruptcy trust discovery and/or authorizations to
assist in the procurement of bankruptcy documents, but the use of the information is limited
to the defendants in each particular case.
9) Records to be Requested. Plaintiff has provided or will provide via interrogatory answers a
list of Plaintiff's known employers, union membership and military service, including the
time period, by year, for each. Plaintiff has provided or will provide via interrogatory
answers and answers to requests for production of documents a list of all medical providers
and bankruptcy trusts a submission was made to and/or any bankruptcy trust compensation
was received for plaintiff.
Bankruptcy trust records will be requested from trusts named on plaintiff's answer to
standard interrogatories and requests for production of documents. Defendants may request
trust submissions from any other trust the defendants believe possess records for plaintiff.
If Forman Perry requests records from a trust not listed in plaintiff's discovery responses,
Forman Perry shall immediately notify plaintiff in writing of the identity of the trust and date
those records were requested. All records shall be timely produced without reservation.
10) Requests for Records. As soon as possible, Forman Perry may begin requesting medical,
Social Security Administration, military, employment, and union records for which an
authorization is tendered. If Forman Perry requests records from a "secondary source" (i.e. a
provider not listed in plaintiffs discovery answers and/or whose identity is learned from
receipt of provider records), Forman Perry shall immediately notify plaintiff in writing of the
identity of the provider and date those records were ordered. All records shall be timely
produced without reservation.
(
11) Transmittal of Records. Forman Perry will provide Plaintiff with portable document format
("PDF") files of all documents it receives in response to requests to medical, Social Security
Administration, military, employment, and union records and bankruptcy trusts. These
documents will be OCRed (optical character recognition), burned to CD and sent to plaintiff
within 5 days ofreceipt by Forman Perry. CDs will be sent via FedEx standard overnight
delivery using the FedEx account number provided by Plaintiff to:
Robert Niewiarowski
Docket Manager
Cascino Vaughan Law Offices.
220 South Ashland Avenue
Chicago, Illinois 60607
Plaintiff shall be responsible for immediate payment of costs incurred for compilation of the
CDs which are provided.
12) Patliology,'X-rays, and all other original lzealtlz records material Forman Perry shall notify
plaintiff within 7 days ofreceiving any pathology materials and/or imaging films. Forman
Perry will notify all relevant defendants of the receipt of all pathology and original x-ray
films on a weekly basis. Plaintiff has the right to request any pathology materials and/or
imaging films obtained by defendant. Defendants will provide these materials via FedEx
standard overnight delivery within 7 days of request to plaintiff using the FedEx account
number provided by plaintiff. Plaintiff will return all pathology matei;ials and imaging films
provided by defendant within 60 days of receipt or no later than 60 days prior to the deadline
for defendants to provide expert reports, whichever shall occur first. The date may be ·
extended by the Court.
Likewise, plaintiff will notify all relevant defendants within 7 days of receiving any
pathology materials and/or imaging films. After sixty (60) days, in which plaintiff may send
the pathology and/or imaging films received to an expert for consultation, Forman Perry has
the right to request any pathology materials and/or imaging films obtained by plaintiff.
Plaintiff will provide these materials via FedEx standard overnight delivery within 7 days of
request. The tracking number of the FedEx package will be provided to Forman Perry the
same day the package is sent. Forman Perry will return 811 pathology materials and imaging
films provided by plaintiff within 60 days of receipt, or no later than 60 days prior to the
deadline for plaintiff to provide expert reports, whichever shall occur first.
In the event that pathology and/or imaging films are received by either plaintiff or defendant
less than 120 days prior to the deadline for filing defendant expert reports, Forman Perry
and/or plaintiffs return of such materials will be shortened by agreement of the parties such
· that both sides have time to have the material reviewed.
13) Non-compliance ofproviders or trusts. This Order expressly dictates that all entities served
with the approved authorization shall accept that authorization as valid and c.omply with all
of its terms. Should any providers or trusts fail to comply with the terms of the authorization,
the party seeking those records may notify the Court and file any and all appropriate motions
with the Court. The Court will address any alleged noncompliance on the part of a trust in an
expedited process.
14) Reports and Attorney Communication. Allen Vaughan of CVLO and Jennifer Studebaker of
Forman Perry are designated as the contact attorneys regarding all records acquisitions
issues. Jennifer Studebaker will confer with Allen Vaughan as needed to confirm receipt of
bankruptcy documents and discuss any issues that have arisen during the collection of
records. Jennifer Studebaker and Allen Vaughan will work together to resolve any problems
arising from this Order.
Nothing in this Order shall be construed to affect any subsequent scheduling order deadlines
implemented by the Court. Any need for extensions of such deadlines will be considered based
on the circumstances of the particular case.
BY~
J 2.D
,,.
JUDGESEPHENL:CROCKER
UNITED STATES MAGISTRATE JUDGE
Exhibit A
Authorization Form For Use and Disclosure of Records, Including Protected
Health Information (Medical Records) Pursuant to HJPAA
To:
'
Re: Patient's Name:
~~~~~~~~~~~~~
Date of Birth:
-~~~~-
I.
RECORDS/INFORMATION TO BE DISCLOSED: This authorization applies to any
and all of the records or documents in your control or possession, whether or not created by you,
including but not limited to the types of records listed below and including but not limited to all
electronically generated or stored records:
1)
2)
3)
4)
5)
6)
7)
8)
All records, reports, test results of other documents concerning the
medical care, treatment, and examination of the aforementioned patient;
All pathology, that is not necessary for care and treatment, original tissue
blocks, original tissue slides, wet tissue, records, self-histories, histochemical
and immunochemical reports, autopsy reports, including but not limited to
hand-written notes and/or drawings associated with the autopsy, test results,
other documents, or electronic information concerning the medical care,
· treatment, and examination of the aforementioned person, including any
photomicrographs, Millipore filters, written tissue digestion protocol or other
material related in any way to any lung tissue asbestos fiber burden analysis
or ferruginous body study performed on the tissues of the aforementioned
patient;
Copies of all correspondence concerning the medical care, treatment,
examination, or physical condition of the aforementioned patient:
Copies of bills or statements of services rendered·for such service:
X-ray films, MRI films, CT films and all other imaging films
involving the aforementioned patient;
Any and all information regarding the patient's SoCial Security records,
including but not limited to 'the information requested on Federal Form SSA7050-F4 ("Request For Social Security Earnings Information");
Ally and all information regarding the patient's U.S. Military records,
including but not limited to the information requested on Federal Form
SFl 80 ("Request Pertaining To Military Records");
Union information and records, including but not limited to:
1.
Application for Qlembership;
2.
Yearly income including number of hours/days worked per year;
~.
Names and addresses of any and all employers, locations of work sites
iticluding any job and/or work logs;
4.
5.
6.
7.
8.
9.
10.
All pension relate. information including doc~ents showing pension
d
contributions by employers;
Documentation of any training participation and information regarding
training materials or trade literature received;
Records of any grievances filed or claimed made for work-related
injuries;
Records of all claims for health, accident, pension or disability
benefits;
All records pertaining to any claim for injuries allegedly during the
course of his employment;
All medical reports and records, infirmary records, return to work
slips, medical excuses and accident reports; and
Records pertaining in any manner to any health screening or
educational sessfons in which the aforementioned person participated
PERSONS, FACILITY, ORGANIZATION, OR CLASS OF PERSONS AUTHORIZED
II.
TO DISCLOSE RECORDS/INFORMATION: The following persons or organizations are
authorized to make the requested use or disclosure of my above-identified protected health
information: See the attached court order, signed by Feqeral Magistrate Stephen L. Crocker.
III.
PERSONS, FACILITY, ORGANIZATION AUTHORIZED TO RECEIVE THE
RECORDS/INFORMATION: The following persons or organizations are authorized to receive
my above-identified protected health information: Cascino Vaughan Law Office, Ltd.; Forman
Perry Watkins Krutz and Tardy, LLP, as representative for all defense firms who have appeared
in the civil action identified below.
PURPOSE FOR AUTHORIZATION - This authorized use or disclosure is for the
following specific purpose(s): at the request of the individual patient/or patient's representative
for use in civil litigation in a civil action concerning asbestos exposures brought on behalf of the
plaintiff and currently pending in the U.S. District Court for the Western District of Wisconsin.
EXPIRATION OF AUTHORIZATION: This authorization will expire upon the
following event: Final resolution of the above-identified civil action.
IV.
AUTHORIZING SIGNATURE OF PATIENT OR PATIENT'S REPRESENTATIVE:
I authorize the use or disclosure of the records/information described below and:
A.
B.
C.
I am not required to sign this authorization and may in fact refuse to
sign this authorization.
I understand that the authorized health care provider will not condition my
treatment or payment for my treatment on my signing this authorization.
I understand that if the person or entity that receives the described
records/information is not subject to federal privacy regulations or other laws.
The records/information may be re-disclosed and no longer protected by those
D.
E.
F.
G.
H.
I.
regulations.
I also understand that certain records may be protected by federal or state
law, including HIV, psychiatric or inental health treatment, alcohol/drug
treatment or communicable diseases, and I am requesting that any and all
such protected records be released under this authorization.
I know that I may inspect or copy the protected health information sought to
be used or disclosed in this authorization as permitted by the federal privacy
·
regulations.
I know that I have the right to revoke this authorization at any time. My
revocation must be in writing and must bear my signature. My revocation
must be submitted to the authorized health care provider disclosed above.
I understand that ifl do revoke this authorization, however, my revocation
will not affect any prior actions taken in reliance on this authorization.
I have discussed this authorization with my attorney and he has advised me
Of my rights pursuant to HIP AA
This authorization does not waive my doctor/patient privilege.
Copies of the above-referenced materials should be numbered. A photostatic copy of this
authorization shall be considered as effective and valid as the original. THIS
AUTHORIZATION DOES NOT AVTHORIZE DISCUSSION OF THE MEDICAL CARE
AND/OR CONDITION OF THE ABOVE PARTY. This Authorization is for securing copies of
any and all requested medical records, X-Rays films, CT films, MRI films, bills, pathology, and
office notes; any and all Social Security records, any and all U.S. Milit~. records, and any and
all Union records as described herein. This does not authorize the securing of a narrative medical
report, nor does it authorize the bearer to conduct ex parte interviews with any medical personnel
regarding the treatme.nts and conditions.
I certify that I have read, signed, and received a copy of this authorjzation.
Signature of Patient (or Patient's Representative)
Patient Representative's Relationship/Capacity to Patient
Printed Name of Personal Representative
Address and Telephone Number of Personal Representative
Date of Signature
ExhibitB
Authorization Form For Use and Disclosure of Plaintiff Bankruptcy Information
To:
Last
Date of Birth:_ _/__/_ _
First
MI
Social Security No.: _ __
Plaintiff's Address:
---------------------
I.
RECORDS/INFORMATION TO BE DISCLOSED: This authorization applies to any
and all records or documents in your control or possession, whether or not created by you,
including but not limited to, the types of records listed below and including, but not limited to,
all electronically generated or stored records as well as all bard copies of records or documents.
(All documents and information shall be provided in their entirety).
a. .
b.
c.
d.
e.
f.
g.
h.
1.
All claims made by the plaintiff or on behalf of the plaintiff by any party,
including claims which ·are paid and/or denied;
All plaintiff claims information including clafui forms, employment records,
product identification information, exposure iilformation and affidavits;
Any and all documents or information provided to the trust in support of or in
relation to plaintiff;
~l records, reports, test results of other documents concerning the medical care,
treatment, and examination of the aforementioned plaintiff;
All correspondence including electronic communication and/or any other
documents exchanged between you and the plaintiff and/or any other party
concerning the claims made by the plaintiff or evaluation of the plaintiff's claim;
All checks or statements of payments made to the plaintiff or his/her
representative including any subsequent payments;
All information related to studies or research done by the trust or its managers to
evaluate bankruptcy claim procedures, payments and valuation;
All information related to the bankruptcy trust procedure for receipt and
acceptance of claims, including the documentation related to receipt of plaintiffs
claun; and
All information related to the bankruptcy trusts procedure for submission,
evaluation, analysis and payment of claims.
II.
PERSONS, FACILITY, ORGANIZATION, OR CLASS OF PERSONS AUTHORIZED
TO DISCLOSE RECORDS/INFORMATION: The following persons or organizations are
authorized to make the requested use or disclosure of my above-identified protected personal and
health information. See the attached court order, signed by Federal Magistrate Stephen L .
. Crocker.
III.
PERSONS, FACILITY, ORGANIZATION AUTH:ORIZED TO RECEIVE THE
.
RECORDS/INFORMATION: The following persons or organizations are authorized to receive
my above-identified protected health information: Cascino Vaughan Law Offices, Ltd.; Forman
Perry Watkins Krutz and Tardy, LLP, as representative for numerous defense firms as well as
any other defense firm who represents a pending party in this litigation as reflected on the court
docketing system (PACER).
·IV.
PURPOSE FOR AUTHORIZATION: This authorized use or disclosure is for the
following specific currently pending in the U.S. District Court for the Western District of
Wisconsin.
V.
EXPIRATION OF AUTHORIZATION: This authorization will expire six months after
the date of signature.
VI.
AUTHORIZING SIGNATURE OF PLAINTIFF OR PLAINTIFF'S·
REPRESENTATIVE: · authorize the use or disclosure of the records/information described
r
below and:
a.
b.
c.
d.
e.
f.
I am not required to sign this authorization and may in fact refuse to sign this
authorization. ·
I understand that the authorized entity will not condition my claim or any
payment made thereon based on my signing this authorization.
I understand that if the person or entity that receives the described
records/information is not subject to federal privacy regulations or other laws then
· the records/informatiQn may be redisclosed and are no longer protected by those
regulations.
.
I know that! may inspect or copy the information sought to be used or disclosed
in this authorization as permitted by the Federal privacy regulations.
I know that I have the right to revoke this authorization at aµy time. My
revocation must be in writing and must bear my signature. My revocation must be
submitted to the authorized entity named above.
I understand that if! do revoke this authorization, however, my revocation will
A photostatic and/or PDF copy of this authorization shall be considered as
effective and valid as
the original.
I certify that I have read, signed an1 received a copy of this authorization.
Signature of Plaintiff or Plaintiff Representative
Printed Name of Plaintiff or Plaintiff Representative
Date of Signature
EXHIBIT
.
I
-~
REQUEST FOR SOCIAL SECURITY EARNINGS INFORMATION
1. Provide your name as it appears on your most recent Social Security card or the name of the lndlvidual whose
.. ,,, earnings you are requesting .
First Name:
..--.----....-....---.---..--.--....,,..-.-1--r-1._......_,,.._,..__,,__,__,,.--,.---.,...-...--.......--., Mlddle lnitlal:
Last Name:
Social Security Number (SSN)
Date of Birth:
rn
I I I I I I .I
I I I I-[[] -I I I I I
[[] I I I I I I
of Death:
D
One SSN per request
Date
rn
I [[] I
IIIII
other Name(s) Used
(Include Malden Name)
2. What kind of earnings information do you need? (Choose ONE of the following types of earnings or SSA must return this request.)
D Itemized Statement of Earning~ $136
Year(s) Requested:
(Includes the names and addresses of employers)
I Ij Ij j
I I. I I I I I I I J
j j j j
.
Year(s) Requested:
If you check this box, tell us why you need this lnfOrmaUon below.
.
.
.
to
.
·
·
·
·
·
to
Check this box Jr you want the earnings information
D CERTIFIED for an additional $56.00 fee.
D
Certified Yearly Tot~ls of Earnings $56
Year(s) Requested:
(Does not Include the names and addresses of employers)
Yearly earnings totals are FREE to the public If you do not
require certlflcaUon. To obtain FREE yearly totals of
earnings, vlslt our website at www.ssa.gov/myaccount.
Year(s) Requested:
II III IIIII
IIIII IIIII
to
to
3. If you would like this Information sent to someone else, please fill In the information below.
I authorize the Social Security Administration to release the earnings Information to:
Name
.:,•
I
City
ZIP Code
4: I am 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 Soclal Security records is
punishable by a fine of not more than $5,000 or one year in prison.
·
Signature AND Printed Name of Individual or Legal Guardian
SSA must receive this form within 120 days from the date 6/gned
Date:
RelaUonshlp (If appr.cable, you must attach proof)
LD'LD' I I I 1 ;
.1
Daytime Phone:
Address
State
City
ZIP Code
Witnesses must sign this form ONl.Y If the above signature Is by marked (X). ff signed by mark (X), two witnesses to the signing who know the slgnee
must sign below and provide their full addresses. Please print the slgnea's name next to the mark (X) on the signature line above.
1. Signature of Witness
2. Signature ofWilness
Address (Number end Street, City, stale end ZIP Code)
, Form SSA-7050-F4 (11-2014) EF (11-2014)
Address (Nwnber end Sl!fle~ City, Stele and ZJP Code)
Page2
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