2020 CA 000976 - BOURNE, ALLISON vs. TARGET CORPORATION A FOREIGN PROFIT CORPORATION

SUMMARY

Back I PrinJudge: DANNHEISSER., THOMAS Case Type: PREMISES LIABILITY - COMMERCIAL Status: OPEN

Case Number: 2020 CA 000976 Uniform Case Number: 172020CA000976XXXXXX

Clerk File Date: 7/31/2020 Status Date: 7/31/2020

SAO Case Number: Total Fees Due: 0.00

Agency: Agency Report #: Custody Location:

PARTIES

!TYPE PARTY NAME ATTORNEY

PLAINTIFF BOURNE, ALLISON

DEFENDANT TARGET CORPORATION A FOREIGN PROFIT CORPORATION

/4, OAKEY, WYATT M (Main Attorney)

STOKES, JOSEPH B III

1 EVENTS

1 DATE EVENT JUDGE LOCATION

No Events on Case

CASE HISTORY

RESULT

CASE NUMBER CHARGE DESCRIPTION CASE STATUS DISPOSITION OUTSTANDING AMOUNT

No Additional Cases

CASE DOCKETS

I MAGE DATE

Request 9/8/2020

Request 9/8/2020

Request 9/8/2020

ENTRY

NOTICE OF SERVICE OF DEFENDANTS FIRST INTERROGATORIES TO PLAIINTIFF ALLISON BOURN

DEFENDANTS FIRST REQUEST FOR PRODUCTION TO PLAINTIFF ALLISON BOURN

DEFENDANT, TARGET CORPORATION'S, ANSWER AND AFFIRMATIVE DEFENSES TO PLAINTIFF'S COMPLAINT

9/3/2020 NOTICE OF APPEARANCE OF COUNSEL AND EMAIL DESIGNATION

777e78/27/2020 SUMMONS RETURNED SERVED

NEXT EVENT ALERTS

8/3/2020 WOAKEY@FORTHEPEOPLE.COM, WMOSERVICE@FORTHEPEOPLE.COM, JSTOKES®SAALFIELDLAW.COM, LLOVEIN@SAALFIELDLAW.COM, WDEAN@SAALFIELDLAW.COM,

RJCSMITH@SAALFIELDLAW.COM

Request 8/3/2020 SUMMONS ISSUED

Request 8/3/2020 PAYMENT $410.00 RECEIPT #2020052684

Request I

8/3/2020 PLAINTIFFS ATTORNEY: OAKEY, WYATT M ASSIGNED

8/3/2020

7/31/2020

DANNHEISSER., THOMAS: ASSIGNED

COMPLAINT

7/31/2020 COVERSHEET

7/31/2020 CASE FILED 07/31/2020 CASE NUMBER 2020 CA 000976

EXH BIT

Case 3:20-cv-05826-TKW-HTC Document 1-1 Filed 09/17/20 Page 1 of 37
Filing # 111103057 E-Filed 07/31/2020 01:01:53 PM

FORM 1.997. CIVIL COVER SHEET

The civil cover sheet and the information contained in it neither replace nor supplement the filing and service of

pleadings or other documents as required by law. This form must be filed by the plaintiff or petitioner with the

Clerk of Court for the purpose of reporting data pursuant to section 25.075, Florida Statutes. (See instructions

for completion.)

I. CASE STYLE

IN THE CIRCUIT COURT OF THE FIRST JUDICIAL CIRCUIT,

I N AND FOR ESCAMBIA COUNTY, FLORIDA

Case No.: 

Judge: 

Allison Bourne

Plaintiff

vs.

Target Corporation c/o CT Corporation System

Defendant

II. AMOUNT OF CLAIM

Please indicate the estimated amount of the claim rounded to the nearest dollar $30,001

III. TYPE OF CASE (If the case fits more than one type of case, select the most definitive category.) If the

most descriptive label is a subcategory (is indented under a broader category), place an x on both the main

category and subcategory lines.

•Condominium

O Contracts and indebtedness

O Eminent domain

O Auto negligence

NI Negligence — other

O Business governance

D Business torts

D Environmental/Toxic tort

D Third party indemnification

O Construction defect

O Mass tort

O Negligent security

D Nursing home negligence

Premises liability — commercial

D Premises liability — residential

0 Products liability

O Real Property/Mortgage foreclosure

D Commercial foreclosure

D Homestead residential foreclosure

O Non-homestead residential foreclosure

O Other real property actions

O Professional malpractice

D Malpractice — business

O Malpractice — medical

j .0 Malpractice — other professional

0Other

0 Antitrust/Trade Regulation

O Business Transaction

CI Circuit Civil - Not Applicable

El Constitutional challenge-statute or ordinance

j . Constitutional challenge-proposed amendment

O Corporate Trusts

El Discrimination-employment or other

O Insurance claims

O Intellectual property

O Libel/Slander

O Shareholder derivative action

O Securities litigation

O Trade secrets

El Trust litigation

0 County Civil

O Small Claims up to $8,000

Civil

• Replevins

• Evictions

O Other civil (non-monetary)

Case 3:20-cv-05826-TKW-HTC Document 1-1 Filed 09/17/20 Page 2 of 37
COMPLEX BUSINESS COURT

This action is appropriate for assignment to Complex Business Court as delineated and mandated by the

Administrative Order. Yes El No

IV. REMEDIES SOUGHT (check all that apply):

Monetary;

El Non-monetary declaratory or injunctive relief;

0 Punitive

V. NUMBER OF CAUSES OF ACTION:

(Specify)

VI. IS THIS CASE A CLASS ACTION LAWSUIT?

Cl Yes

X No

VII. HAS NOTICE OF ANY KNOWN RELATED CASE BEEN FILED?

No

El Yes — If "yes" list all related cases by name, case number and court:

VIII. IS JURY TRIAL DEMANDED IN COMPLAINT?

[ZI Yes

El No

I CERTIFY that the information I have provided in this cover sheet is accurate to the best of my knowledge and belief, and

that I have read and will comply with the requirements of Florida Rule of Judicial Administration 2.425.

Signature: s/ Wyatt Oakey

Attorney or party

FL Bar No.: 96471

(Bar number, if attorney)

Wyatt Oakey

(Type or print name)

Date: 07/31/2020

Case 3:20-cv-05826-TKW-HTC Document 1-1 Filed 09/17/20 Page 3 of 37
Filing # 111103057 E-Filed 07/31/2020 01:01:53 PM

IN THE CIRCUIT COURT OF THE FIRST JUDICIAL DISTRICT IN AND FOR

ESCAMBIA COUNTY, FLORIDA, CIVIL DIVISION

ALLISON BOURN, CASE NO.:

Plaintiff,

V.

TARGET CORPORATION,

a Foreign Profit Corporation,

Defendant.

COMPLAINT

Plaintiff ALLISON BOURN, by and through her undersigned attorneys, sues Defendant,

TARGET CORPORATION, a Foreign Profit Corporation and alleges:

COMMON ALLEGATIONS AS TO ALL COUNTS

1. This is an action for damages that exceed the sum of THIRTY THOUSAND

DOLLARS ($30,000.00), exclusive of costs, interest and attorneys' fees (The estimated value of

Plaintiff's claim is in excess of the minimum jurisdictional threshold required by this Court).

Accordingly, Plaintiff has entered "$30,001" in the civil cover sheet for the "estimated amount of

the claim" as required in the preamble to the civil cover sheet for jurisdictional purposes only (the

Florida Supreme Court has ordered that the estimated "amount of claim" to be set forth in the civil

cover sheet for data collection and clerical purposes only). The actual value of Plaintiff's claim will

be determined by a fair and just jury in accordance with Article 1, Section 21, Fla. Const.

2. At all times material hereto, Plaintiff ALLISON BOURN was a resident of

Pensacola, Escambia County, Florida.

1

Case 3:20-cv-05826-TKW-HTC Document 1-1 Filed 09/17/20 Page 4 of 37
3. At all times material to this action, Defendant, TARGET CORPORATION, was

and remains a Foreign Profit Corporation authorized to do business and doing business at 4711

Bayou Blvd., Pensacola, Florida.

4. At all times material hereto, Defendant, TARGET CORPORATION, was in

possession of, owned, maintained, managed, and/or controlled a retail department store of that

certain business known as Target, located at 4711 Bayou Blvd., Pensacola, Florida, said business

being open to the general public, including the Plaintiff herein.

5. At said time and place, Plaintiff, ALLISON BOURN, was an invitee at the Target

retail department store in which Defendant, TARGET CORPORATION, owned, maintained,

managed, and/or controlled.

6. On or about December 22, 2019, Plaintiff visited Defendant, TARGET

CORPORATION's subject premises to purchase items from the Defendant, TARGET

CORPORATION's retail department store.

7. At said time and place, Plaintiff, ALLISON BOURN, slipped in a puddle of liquid

and fell to the floor while walking down an aisle of Defendant, TARGET CORPORATION'S,

resale store.

8. At said time and place, Plaintiff was an invitee at said retail store, lawfully upon the

premises of the Defendant, TARGET CORPORATION, which owed Plaintiff a duty to exercise

reasonable care for her safety.

9. At said time and place, Defendant, TARGET CORPORATION, breached its nondelegable duty owed to Plaintiff, ALLISON BOURN, by committing one or more of the

following omissions or commissions:

2

Case 3:20-cv-05826-TKW-HTC Document 1-1 Filed 09/17/20 Page 5 of 37
a. Negligently failing to maintain or adequately maintain the premises, thus creating

a hazardous condition in the area of the fall to members of the public utilizing

said premises, including the Plaintiff herein, and creating an unreasonably

dangerous slipping hazard, to wit: the puddle of liquid on the floor in the aisle,

being in violation of the applicable building codes and standards and life safety

rules, thus creating an unreasonably dangerous condition for Plaintiff;

b. Negligently failing to maintain or adequately maintain the premises, thus allowing

the puddle of liquid on the floor in the aisle to exist, creating a tripping hazard to

members of the General Public, including the Plaintiff herein, thus creating an

unreasonably dangerous condition for her;

c. Negligently failing to inspect or adequately inspect the floor of the aisle, as

specified above, to ascertain that the floor and above ceiling was not being

properly maintained constituted a slipping hazard to pedestrians, including the

Plaintiff herein, thus creating an unreasonably dangerous condition to her;

d. Negligently failing to inspect or adequately warn the Plaintiff of the danger of the

liquid on the floor in the aisle, when Defendant knew, or through the exercise of

reasonable care should have known, the floor in the aisle was unreasonably

dangerous and that Plaintiff was unaware of same; and

e. Negligently failing to correct or adequately correct the unreasonably dangerous

condition of the ceiling above the aisle on Defendant's premises, when said

condition was either known to Defendant, or had existed for a sufficient length of

3

Case 3:20-cv-05826-TKW-HTC Document 1-1 Filed 09/17/20 Page 6 of 37
time, such that Defendant should have known of same had Defendant exercised

reasonable care.

10. As a result, while Plaintiff was walking down the aisle at Defendant, TARGET

CORPORATION's store, she slipped and fell in the puddle on the floor in the aisle, which

resulted in the injuries as set forth.

11. As a direct and proximate result of the negligence of Defendant, TARGET

CORPORATION, Plaintiff, ALLISON BOURN, suffered bodily injury in and about her body and

extremities, resulting in pain and suffering, disability, disfigurement, permanent and significant

scarring, mental anguish, loss of the capacity for the enjoyment of life, expense of hospitalization,

medical and nursing care and treatment, loss of earning, loss of the ability to earn money, and

aggravation of previously existing condition. The losses are either permanent or continuing and

Plaintiff, ALLISON BOURN, will suffer the losses in the future.

WHEREFORE, Plaintiff, ALLISON BOURN, demands judgment against Defendant,

TARGET CORPORATION, for damages, costs of this action, interest, and such other and

further relief as this Court may deem meet and just, and demands a trial by jury on all issues so

triable.

Plaintiff demands trial by jury of all issues so triable.

s/Wyatt M. Oakey

WYATT M. OAKEY, ESQUIRE

FL Bar No.: 96471

MORGAN & MORGAN, PLLC

220 W. Garden St., 9

th

Floor

Pensacola, FL 32502

Telephone: 850-316-9069

Facsimile: 850-316-9105

Secondary Telephone: 850-876-7804

4

Case 3:20-cv-05826-TKW-HTC Document 1-1 Filed 09/17/20 Page 7 of 37
Secondary Facsimile: 850-876-7828

woakey@forthepeople.com

wmoservic(e &,forthepeople.com

Attorney for Plaintiff

5

Case 3:20-cv-05826-TKW-HTC Document 1-1 Filed 09/17/20 Page 8 of 37
Escambia County Receipt of Transaction

Receipt # 2020052684

Cashiered by: mbp

Received From

OAKEY, WYATT M

220 W GARDEN ST STE 900

PENSACOLA, FL 32502

On Behalf Of:

CaseNumber 2020 CA 000976

Fee Description

(CA1) CIRCUIT CIVIL FILING FEE

(CA93) ISSUANCE OF SUMMONS

Total:

Grand Total:

Fee Prior Paid

400.00 0.00

10.00 0.00

Pam Childers

Clerk of Court

Escambia County, Florida

On: 8/3/20 11:29 am

Transaction # 101500367

Waived Due Paid Balance

0.00 400.00 400.00 0.00

0.00 10.00 10.00 0.00

410.00 0.00

410.00 0.00

0.00 410.00

0.00 410.00

410.00 0.00

410.00 0.00

PAYMENTS

Payment Type Reference Amount Refund Overage Change Net Amount

EFILING 28665876 OK 410.00 0.00 0.00 0.00 410.00

Payments Total: 410.00 0.00 0.00 0.00 410.00

Credit Card Convenience fee of 3.5% is non-refundable. Page 1 of 1

Case 3:20-cv-05826-TKW-HTC Document 1-1 Filed 09/17/20 Page 9 of 37
IN THE CIRCUIT COURT IN AND FOR ESCAMBIA COUNTY, FLORIDA

ALLISON BOURNE

PLAINTIFF,

Vs. CASE NO: 2020 CA 000976

DIVISION: F

TARGET CORPORATION A FOREIGN PROFIT CORPORATION

DEFENDANT,

SUMMONS

THE STATE OF FLORIDA:

To Each Sheriff of the State:

YOU ARE COMMANDED to serve this summons and a copy of the complaint in the above styled

cause upon the defendant TARGET CORPORATION A FOREIGN PROFIT CORPORATION

C/O CT CORPORATION SYSTEM 1200 S. PINE ISLAND ROAD PLANTATION, FL 33324

Each defendant is hereby required to serve written defenses to said complaint on

plaintiffs attorney(s), whose address is

WYATT M OAKEY

220 W GARDEN ST STE 900

PENSACOLA, FL 32502

within 20 days after service of this summons upon you, exclusive of the day of service, and to file the

original of said written defenses with the Clerk of said Court either before service on said attorney or

immediately thereafter. If you fail to do so, a default will be entered against you for the relief demanded

in the complaint.

Witness, my hand and the seal of this Court on this 3rd day of August, 2020

;- 114,!.9f . 4Yr#' 11 k 1041, •

By :

PAM CHILDERS

CLERK OF THE CIRCUIT COURT

Deputy Clerk

'COM"

* Except when suit is brought pursuant to Section 768.28, Florida Statutes, if the State of Florida, one of

its agencies, or one of its officials or employees sued in his or her official capacity is a defendant, the

time to be inserted as to it is 40 days. When suit is brought pursuant to Section 768.28, Florida Statutes,

the time to be inserted is 30 days.

CAS UM205 3P

Case 3:20-cv-05826-TKW-HTC Document 1-1 Filed 09/17/20 Page 10 of 37
Filing # 112482054 E-Filed 08/27/2020 12:43:50 PM

Nt-1-1LEAVI I LP- ttIVIL.t

Case:

2.020 CA

000976

Court:

I N THE CIRCUIT COURT, FIRST JUDICIAL CIRCUIT, IN AND

FOR ESCAMBIA COUNTY, FLORIDA

County;

Escambia

Job:

4793446 (9883919 )

Plaintiff / Petitioner:

ALLISON BOURNE

Defendant / Respondent:

TARGET CORPORATION, A FOREIGN PRUFIT CORPORATION

Received by:

Legalis International

For:

Morgan & Morgan

To be served upon:

TARGET CORPORATION A FOREIGN PROFIT CORPORATION C/O CT CORPORATION SYSTEM

UGOCHUKWU NWABUEZE, being duly sworn, depose and say: I am over the age of 18 years and not a party to this action, and that within

the boundaries of the state where service was effected, I was authorized by law to make service of the documents and informed said

person of the contents herein

Recipient Name Address: Donna tvioch, 1200 S. PINE ISLAND ROAD PLANTATION, FL 33324

Manner of Service: Corporation, Aug 19, 2020, 2:50 pm EDT

Documents: SUMMONS; COMPLAINT.

Additional Comments:

Successful Attempt: Aug 19, 2020, 150 pm EDT at 1200 S. PINE ISLAND ROAD PLANTATION, FL 33324 rec&ved by Donna Moch. Age; 53;

Ethnicity: Caucasian; Gender: Female; Weight: 150; Height: 5'3'; Hair: Brown; Refationship: Manager;

UGO KWU NWABUEZE

Legalis I nternational

Date

Subscribed and sworn to befiqe me by the affair who is

personally knowitrra me. "'4

Commission Ex res

147. tViftsVSI:tembor 'Gwilt"tjG°223 222f3,4,8

l'of no* Bondod th„,, B,49,44,41,

sew" AWN Pecolit 4041

gOria lequtelditS sLiKtri

StitrZ # ocqsslult003 • 4

(m) -)n ll IA

Case 3:20-cv-05826-TKW-HTC Document 1-1 Filed 09/17/20 Page 11 of 37
Filing # 112859554 B-Filed 09/03/2020 02:19:24 PM

IN THE CIRCUIT COURT, FIRST

JUDICIAL CIRCUIT, IN AND FOR

ESCAMBIA COUNTY, FLORIDA

CASE NO.: 2020-CA-000976

DIVISION: F

ALLISON BOURN,

Plaintiff,

vs.

TARGET CORPORATION,

a foreign profit corporation,

Defendant.

NOTICE OF APPEARANCE AND DESIGNATION

OFEMAIL ADDRESSESFORSERVICE OFDOCUMENTS

COMES NOW, Joseph B. Stokes, III, Esquire, of SAALFIELD SHAD, P.A., and files this

Notice of Appearance as attorney of record in the above-captioned matter on behalf of the

Defendant, TARGET CORPORATION.

Pursuant to Florida Rule of Judicial Administration 2.516(1)(A), Defendant hereby gives

notice of the primary and secondary email addresses of its counsel as follows:

Counsel's Name Joseph B. Stokes, III

Primary Email Address: jstokes@saalfieldlaw.com

Secondary Email Addresses: llovein@saalfieldlaw.com;

wdea(n&,saalfieldlaw.com

Tertiary Email Address: rjcsmith@saalfieldlaw.com

CERTIFICATE OFSERVICE

I HEREBY CERTIFY that a true and correct copy of the foregoing has been e-filed with

the Clerk of the Court by using the Florida Courts Portal system and furnished to the following

named addressees via email on this 3rd day of September, 2020:

Case 3:20-cv-05826-TKW-HTC Document 1-1 Filed 09/17/20 Page 12 of 37
Wyatt M. Oakey, Esquire

Morgan & Morgan, P.A.

220 West Garden Street, 9th Floor

Pensacola, FL 32502

Email: woakey@forthepeople.com;wmoservice@forthepeople.com

Telephone: 850-316-9069

Facsimile: 850-316-9105

Attorneys for Plaintiff

SAALFIELD SHAD, P.A.

/s/ Joseph B. Stokes, III

JOSEPH B. STOKES, III, ESQUIRE

Florida Bar Number: 897183

Email (Primary) jstokes@saalfieldlaw.com

Email (Secondary) llovein@saalfieldlaw.com;

wdean@saalfieldlaw.com

RUBY JO CATHERINE SMITH, ESQUIRE

Florida Bar Number: 112741

Email (Primary) rjc(s a),saalfieldlaw.com

245 Riverside Avenue, Suite 400

Jacksonville, FL 32202

904-355-4401 (phone)

904-355-3503 (facsimile)

Attorneys for Defendant

2

Case 3:20-cv-05826-TKW-HTC Document 1-1 Filed 09/17/20 Page 13 of 37
Filing # 112980208 E-Filed 09/08/2020 10:50:20 AM

IN THE CIRCUIT COURT, FIRST

JUDICIAL CIRCUIT, IN AND FOR

ESCAMBIA COUNTY, FLORIDA

CASE NO.: 2020-CA-000976

DIVISION: F

ALLISON BOURN,

Plaintiff,

vs.

TARGET CORPORATION,

a foreign profit corporation,

Defendant.

DEFENDANT,TARGET CORPORATION'S,ANSWERAND AFFIRMATIVE

DEFENSES TOPLAINTIFF'S COMPLAINT

Defendant, Target Corporation, by and through its undersigned counsel, hereby answers

Plaintiff's Complaint, and states as follows:

1. Admitted for jurisdictional purposes only that Plaintiff contends the damages in this case

exceed 30,000, otherwise denied.

2. Admitted.

3. Admitted that Defendant Target Corporation is a foreign corporation that operated a

business at 4711 Bayou Blvd., Pensacola, Florida, otherwise denied.

4. Admitted that Defendant Target Corporation operated a business at 4711 Bayou Blvd.,

Pensacola, Florida, otherwise denied.

5. Denied.

6. Denied.

7. Denied.

8. Denied.

Case 3:20-cv-05826-TKW-HTC Document 1-1 Filed 09/17/20 Page 14 of 37
9. Denied, including all subparts.

10. Denied.

1 1. Denied.

AFFIRMATIVEDEFENSES

First Affirmative Defense

The Plaintiff, ALLISON BOURN, was herself negligent, which negligence was the

proximate or contributing cause of her injury and/or injuries. Therefore, any recovery in this action

should be reduced on a pro rata basis based upon the degree of her negligence.

Second Affirmative Defense

This Defendant is entitled to a set-off for any and all benefits received by the Plaintiff from

any collateral source as defined by applicable Florida Statutes and case law.

Third Affirmative Defense

The Plaintiff has failed to mitigate her damages in this case, which failure to mitigate

should reduce her claim for damages in direct proportion thereto.

Fourth Affirmative Defense

Defendant asserts § 768.0755, Florida Statutes, as a defense to this case.

Demand for Jury Trial

Defendant hereby demands a jury trial on all issues so triable.

CERTIFICATE OF SERVICE

I HEREBY CERTIFY that a true and correct copy of the foregoing has been e-filed with

the Clerk of the Court by using the Florida Courts Portal system and furnished to the following

named addressees via email on this 8th day of September, 2020:

Wyatt M. Oakey, Esquire

Morgan & Morgan, P.A.

220 West Garden Street, 9th Floor

2

Case 3:20-cv-05826-TKW-HTC Document 1-1 Filed 09/17/20 Page 15 of 37
Pensacola, FL 32502

Email: woake(y&forthepeople.com,wmoservice@forthepeople.com

Telephone: 850-316-9069

Facsimile: 850-316-9105

Attorneys for Plaintiff

SAALFIELD SHAD, P.A.

/s/ Joseph B. Stokes, III

JOSEPH B. STOKES, HI, ESQUIRE

Florida Bar Number: 897183

Email (Primary) istoke(s&,saalfieldlaw.com

Email (Secondary) Hovein@saalfieldlaw.com,

wdean@saalfieldlaw.com

RUBY JO CATHERINE SMITH, ESQUIRE

Florida Bar Number: 112741

Email (Primary) rjcs@saalfieldlaw.com

245 Riverside Avenue, Suite 400

Jacksonville, FL 32202

904-355-4401 (phone)

904-355-3503 (facsimile)

Attorneys for Defendant

3

Case 3:20-cv-05826-TKW-HTC Document 1-1 Filed 09/17/20 Page 16 of 37
Filing # 112980208 E-Filed 09/08/2020 10:50:20 AM

IN THE CIRCUIT COURT, FIRST

JUDICIAL CIRCUIT, IN AND FOR

ESCAMBIA COUNTY, FLORIDA

CASE NO.: 2020-CA-000976

DIVISION: F

ALLISON BOURN,

Plaintiff,

vs.

TARGET CORPORATION,

a foreign profit corporation,

Defendant.

DEFENDANT'SFIRSTREOUEST FORPRODUCTION TO

PLAINTIFFALLISON BOURN

Defendant, Target Corporation, by and through its undersigned attorneys, hereby requests

pursuant to Rule 1.350, Florida Rules of Civil Procedure, that Plaintiff, ALLISON BOURN,

produce and permit Defendant to inspect and copy each of the following documents:

1. Medical bills, including but not limited to doctors, hospitals and prescriptions

arising out of the alleged injuries which are the subject of your Complaint.

2. Income tax returns for the years 2015 through 2019, including W-2 forms filed.

3. Hospital records concerning any and all hospitalizations arising out of the alleged

injuries to Plaintiff which are in your or your attorney's possession, custody or control.

4. Medical records from any doctors, nurses or other health care providers who have

seen and/or treated Plaintiff as a result of the alleged injuries pled in the Complaint.

5. Medical reports, opinions or other written memoranda from doctors, nurses or other

health care providers, or expert witnesses containing information concerning the injuries and/or

Case 3:20-cv-05826-TKW-HTC Document 1-1 Filed 09/17/20 Page 17 of 37
damages allegedly sustained by Plaintiff which are in your or your attorney's possession, custody

or control.

6. Any and all photographs taken in relation to this incident.

7. Any and all statements obtained in relation to this case.

8. All documents which you anticipate you may utilize as exhibits in the trial of this

matter.

9. A copy of the front and back of all health insurance cards including Medicare,

Medicaid, and/or private health insurance carriers in possession of the Plaintiff at the time of the

accident and anytime thereafter.

10. All documents and payment information made by third party/collateral source lien

holders received by Plaintiff or Plaintiff's counsel in connection with the subject accident.

1 1. All documents sent by Plaintiff's counsel to any collateral source lien holders

advising them of the subject accident and/or putting said collateral source lien holder on notice.

12. All documents sent by Plaintiff or received by Plaintiff in connection with any

disability insurance in effect at the time of the subject accident.

13. An original Consent to Release directed to Centers for Medicare & Medicaid

Services (CMS) executed by Plaintiff. (Attached hereto).

14. An original Consent for Release of Information directed to Social Security

Administration executed by Plaintiff. (Attached hereto).

15. An original Authorization for the Use and Disclosure of Protected Health

Information directed to Florida Medicaid TPL Recovery Program executed by Plaintiff. (Attached

hereto).

2

Case 3:20-cv-05826-TKW-HTC Document 1-1 Filed 09/17/20 Page 18 of 37
16. An original Request for Copy of Tax Return IRS Form 4506 directed to the Internal

Revenue Service executed by Plaintiff. (Attached hereto).

17. Copies of all records related to any mental health treatment received by Plaintiff in

the last ten (10) years, including but not limited to, psychologists, psychiatrists, counselors or

therapists. This request specifically includes records of treatment for substance abuse, dependency

or addiction.

18. The shoes worn by the Plaintiff at the time of the incident alleged in Plaintiff's

Complaint.

CERTIFICATE OFSERVICE

I HEREBY CERTIFY that a true and correct copy of the foregoing has been e-filed with

the Clerk of the Court by using the Florida Courts Portal system and furnished to the following

named addressees via email on this 8th day of September, 2020:

Wyatt M. Oakey, Esquire

Morgan & Morgan, P.A.

220 West Garden Street, 9th Floor

Pensacola, FL 32502

Email: woakey@forthepeople.com,wmoservice@forthepeople.com

Telephone: 850-316-9069

Facsimile: 850-316-9105

Attorneys for Plaintiff

SAALFIELD SHAD, P.A.

/s/ Joseph B. Stokes, III

JOSEPH B. STOKES, III, ESQUIRE

Florida Bar Number: 897183

Email (Primary) jstokes@saalfieldlaw.com

Email (Secondary) Hovein@saalfieldlaw.com,

wdean@saalfieldlaw.com

RUBY JO CATHERINE SMITH, ESQUIRE

Florida Bar Number: 112741

Email (Primary) rjcs@saalfieldlaw.com

245 Riverside Avenue, Suite 400

Jacksonville, FL 32202

3

Case 3:20-cv-05826-TKW-HTC Document 1-1 Filed 09/17/20 Page 19 of 37
904-355-4401 (phone)

904-355-3503 (facsimile)

Attorneys for Defendant

4

Case 3:20-cv-05826-TKW-HTC Document 1-1 Filed 09/17/20 Page 20 of 37
Form 4506

(March 2019)

Department of the Treasury

Internal Revenue Service

Request for Copy of Tax Return

00- Do not sign this form unless all applicable lines have been completed.

fob Request may be rejected if the form is incomplete or illegible.

1. 0 For more information about Form 4506, visit wwwirs.gov/form4506.

OMB No. 1545-0429

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 (such 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.

la Name shown on tax return. If a joint return, enter the name shown first. lb First social security number on tax return,

individual taxpayer identification number, or

employer identification number (see instructions)

2a If a joint return, enter spouse's name shown on tax 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 If the tax return is to be mailed to a third party (such as a mortgage company), enter the third party's name, address, and telephone number.

Saalfield Shad, P.A., 245 Riverside Avenue, Suite 400, Jacksonville, FL 32202, Telephone No.: 904-355-4401, Fax No.: 904-355-3503

Caution; If the tax return 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

i nformation, 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. 0. 1040

Note: If the copies must be certified for court or administrative proceedings, check here . . •

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.

12/31/2019 12/31/2018

12/31/2015

12/31/2017 12/31/2016

Fee. There is a $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, lTlN,

or EIN and "Form 4506 request" on your check or money order.

a Cost for each return . . •

b Number of returns requested on line 7 .

•

•

c Total cost. Multipl y l ine8a by line8b . . , . , . , . . . . I • I,

,•-• FM., I -.I fr• f . . - 14, NI ,..... I . MI .1 - , -

9 If we cannot find the tax return, we will refund the fee. If the refund should go to the third party

Caution:Do not sign thisform unless all applicable lines have been completed.

$ 50.00

5

• • $250.00

isted on line 5, check here .

Signature of taxpayer(s). I declare that I am either the taxpayer whose name is shown on line la or 2a, or a person authorized to obtain the tax return

requested. If the request applies to a joint return, at least one spouse must sign. If signed by a corporate officer, 1 percent or more shareholder, partner,

managing rnerrter, guardian, tax matters partner, executor, receiver, administrator, trustee, or party other than the taxpayer, I 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.

Signatory attests that he/she has read the attestation clause and upon so reading

declares that he/she has the authority to sign the Form 4506. See instructions. Phone number of taxpayer on line

l a or 2a

Sign Signature (seeinstructions)

Here

Date

Title (if line la above is a corporation, partnership, estate, rtrust)

Spouse's signature

For Privacy Act and Paperwork Reduction Act Notice, see page 2.

Date

Cat. No. 41721E Form 4506 (Rev. 3-2019)

Case 3:20-cv-05826-TKW-HTC Document 1-1 Filed 09/17/20 Page 21 of 37
Form 4506 (Rev. 3-2019) 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.gov/form4506.

Information about any recent developments affecting

Form 4506, Form 4506-1 and Form 4506T-EZ will be

posted on that page.

General Instructions

Caution: Do not sign this form unless all applicable

lines have been completed.

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

return.

Chart for individual returns

(Form 1040 series)

If you filed an

individual return Mail to:

and lived in:

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

A.P.O. or F.P.O. address

Internal Revenue Service

RAIVS Team

Stop 6716 AUSC

Austin, TX 73301

Alaska, Arizona,

Arkansas, California,

Colorado, Hawaii, Idaho,

Illinois, Indiana, Iowa,

Kansas, Michigan,

Minnesota, Montana,

Nebraska, Nevada, New

Mexico, North Dakota,

Oklahoma, Oregon,

South Dakota, Utah,

Washington, Wisconsin,

Wyoming

Internal Revenue Service

RAIVS Team

Stop 37106

Fresno, CA 93888.

Connecticut,

Delaware, District of

Columbia, Florida,

Georgia, Maine,

Maryland,

Massachusetts,

Missouri, New

Hampshire, New Jersey,

New York, North

Carolina, Ohio,

Pennsylvania, Rhode

Island, South Carolina,

Vermont, Virginia, West

Virginia

Internal Revenue Service

RAIVS Team

Stop 6705 5-2

Kansas City, MO

64999

Chart for all other returns

If you lived in

or your business Mail to:

was in:

Alabama, Alaska,

Arizona, Arkansas,

California, Colorado,

Connecticut, Delaware,

District of Columbia,

Florida, Georgia, Hawaii,

Idaho, Illinois, Indiana,

Iowa, Kansas, Kentucky,

Louisiana, Maine,

Maryland,

Massachusetts,

Michigan, Minnesota,

Mississippi,

Missouri, Montana,

Nebraska, Nevada, New

Hampshire, New Jersey,

New Mexico, New York,

North Carolina,

North Dakota. Ohio,

Oklahoma, Oregon,

Pennsylvania, Rhode

Island, South Carolina,

South Dakota,

Tennessee, Texas, Utah,

Vermont, Virginia,

Washington, West

Virginia, Wisconsin,

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

Specific Instructions

Line lb. Enter your employer identification number

(EIN) if you are requesting a copy of a business

return. 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 C (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 la 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 a

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 only if this

authority has been specifically delegated to the

representative on Form 2848, line 5a. Form 2848

showing the delegation must be attached to Form

4506.

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 returns) and

respond to your request. If you request a copy of a

tax return, 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 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 4506

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.

if you 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.

Case 3:20-cv-05826-TKW-HTC Document 1-1 Filed 09/17/20 Page 22 of 37
RON DESANTIS

GOVERNOR

MARY C. MAYHEW

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 the information 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 the Florida Medicaid TPL Recovery Program. This form must be completed and signed by the Medicaid recipient or by an

individual 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).

PLEASE COMPLETE THE FOLLOWING SECTIONS

1. Personal Information:

Medicaid Recipient's Name Date of Birth 

Medicaid ID Number Social Security Number 

2. I give permission to the Agency for Health Care Administration (AHCA) and its contract representatives to share the health information

listed below with the following:

Name of the Law Firm or Law Office Saalfield Shad,P.A.,245 Riverside Avenue,#400,Jacksonville,FL 32202

Name of the Insurance Company 

Other

3. Indicate the purpose for which the disclosure is to be made:

XXTo substantiate Medicaid's lien relating to a lawsuit

To substantiate Medicaid's claim against the estate or against a trust account or annuity

XX Other Litigation pending in the State of Florida

4. 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].

XX Other, [Please be specific]. Paid Claims History

5. 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.)

I understand that the information described above may be redisclosed by the person or group that I hereby give AHCA and its contract representatives

permission to share my information with, and that my information would no longer be protected by the federal privacy regulations. Therefore, I release

AHCA, its workforce members, and its contract representatives from all liability arising from the disclosure of my health information pursuant to this

agreement. I understand that I may inspect or request copies of any information disclosed by this authorization if AHCA or its contract representatives

i nitiated this request for disclosure. I understand that I may revoke this authorization by notifying AHCA through its contractor representatives, in writing,

knowing that previously disclosed information would not be subject to my revocation request. I understand that I may refuse to sign this authorization and

that my refusal to sign will not affect my ability to obtain treatment, payment or eligibility for benefits.

6. Recipient Signature Print Name Date 

OR

Name of Legal Representative (Print) Relationship 

Signature of Legal Representative * Date 

* If you are not the individual, but represent the individual, please attach a copy of the legal document that verifies that you are a representative (parent

of a minor, legal guardian, trustee, power of attorney, personal representative of the estate, grantor of an annuity).

Case 3:20-cv-05826-TKW-HTC Document 1-1 Filed 09/17/20 Page 23 of 37
INSTRUCTIONS FOR THE USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

1. Complete the front of the form and return it to Florida Medicaid TPL Recovery Program, Post Office Box 12188, Tallahassee, Florida

32317-2188, Phone (toll-free) (877) 357-3268 or Fax (844) 845-8352.

2. If the signer is a guardian, has a power of attorney or is an authorized representative, documentation of the representative's authority

to act on the individual's behalf must be attached. If an agency has custody of a child and a representative signs the release, include a

copy of the custody order.

3. Special kinds of health information have specific laws and rules that have to be followed before that information can be disclosed.

HIV and Sexually Transmitted Diseases (STD): All information about HIV and sexually transmitted diseases is protected under federal

and state laws and cannot be disclosed without your written authorization unless otherwise provided in the regulations. To release HIV

or STD information, this authorization must include a statement in the Information You Want Disclosed section of the specific HIV or STD

information that you are giving permission to release. Re-disclosure of HIV information is not allowed, except in compliance with law or

with your written permission.

Alcohol and Drug Treatment: Alcohol and/or drug treatment records are protected under federal and state laws and regulations and

cannot be disclosed without your written authorization, unless otherwise provided for in federal and state laws or regulations. To release

alcohol and drug treatment information, this authorization must include a statement in the Information You Want Disclosed section of the

specific information that you are giving permission to release, such as "assessment, treatment plan, attendance, discharge plan." Redisclosure of you alcohol and/or drug treatment records is not allowed, except in compliance with law or with your written permission.

Mental Health Treatment: Mental health treatment records are protected under federal and state laws and regulations and cannot be

disclosed without your written authorization, unless otherwise allowed in federal and state laws or regulations. To release mental health

treatment information, this authorization must include a statement in the Information You Want Disclosed section of the specific

i nformation that you are giving permission to release, such as "assessment, treatment plan, attendance, discharge plan." Also, disclosure

of your therapist's own notes (psychotherapy notes) needs separate permission. Re-disclosure of your mental health treatment records

is prohibited, except in compliance with law or with your written permission.

4. You will be provided with a copy of this form.

REVOCATION SECTION

To revoke your authorization, complete the following section and return the form to the Florida Medicaid TPL Recovery Program at the

address given above. (Use of this form to revoke your authorization is optional; however, you must submit your revocation request in

writing.)

I no longer want my information shared.

Name Date of Birth 

Street Address 

City State Zip 

If applicable, your Medicaid ID number 

Signature Date 

OR

Signature of Authorized Representative Date 

Relationship of Authorized Representative 

(Revised March 2019)

Case 3:20-cv-05826-TKW-HTC Document 1-1 Filed 09/17/20 Page 24 of 37
Consent to Release

Liability Insurance (Including Self-Insurance), No-Fault Insurance,

or Workers' Compensation

Where to find Information on "Consent to Release" vs. "Proof of Representation"

Please refer to the PowerPoint document on this website titled: "Rules and Model Language for 'Proof of

Representation' vs. 'Consent to Release' for Medicare Secondary Payer Liability Insurance (Including SelfInsurance), No-Fault Insurance, or Workers' Compensation" for detailed information on

• When to use a "consent to release" document vs. a "proof of representation" document,

• Appropriate content for both documents,

• The need for appropriate documentation when there are two layers of representatives involved (examples:

attorney 1 refers a case to attorney 2; the beneficiary's guardian hires an attorney to pursue a liability

insurance claim) or when a beneficiary's representative signs a "consent to release" document on the

beneficiary's behalf,

• What liability insurers (including self-insurers), no-fault insurers, and workers' compensation entities must

have in order to obtain conditional payment information, and

• Use of agents by insurers' or workers' compensation.

General

A"consent to release" document is used by an individual or entity who does not represent the Medicare

beneficiary but is requesting information regarding the beneficiary's conditional payment information. A

"consent to release" does not authorize the individual or entity to act on behalf of the beneficiary or make

decisions on behalf of the beneficiary.

Model Language

See attached. Use of the model language is not required, but any documentation submitted as a "Consent to

Release" must include the information the model language requests.

Where to Submit a" Consent to Release" document:

Liability Insurance, No-Fault Insurance, Workers' Compensation:

NGHP

PO Box 138832

Oklahoma City, OK 73113

Fax: (405) 869-3309

Case 3:20-cv-05826-TKW-HTC Document 1-1 Filed 09/17/20 Page 25 of 37
MODEL LANGUAGE

CONSENT TO RELEASE

The language below should be used when you, a Medicare beneficiary, want to authorize someone other than

your attorney or other representative to receive information, including identifiable health information, from the

Centers for Medicare & Medicaid Services (CMS) related to your liability insurance (including self-insurance),

no-fault insurance or workers' compensation claim.

(print your name exactly as shown on your Medicare card)

hereby authorize the CMS, its agents and/or contractors to release, upon request, information related to my

injury/illness and/or settlement for the specified date of injury/illness to the individual and/or entity listed

below:

CHECKONLY ONE OFTHEFOLLOWING TOINDICATE WHO MAYRECEIVEINFORMATION

AND THEN PRINTTHE REQUESTEDINFORMATION:

(If you intend to have your information released to more than one individual or entity, you must complete a

separate release for each one.)

insurance Company

Name of entity:

Contact for above entity:

Address:

Address Line 2:

City/State/ZIP:

Telephone:

Workers' Compensation Carrier

Saafield Shad, P.A.

VI

Other Attorney

(Explain)

Joseph B. Stokes, Il l

245 Riverside Avenue

Suite 400

Jacksonville, FL 32202

904-355-4401

CHECKONE OFTHE FOLLOWING TO INDICATE HOW LONG CMS MAYRELEASEYOUR

INFORMATION

(The period you check will run from when you sign and date below.):

7One Year rTTwo Years Other

(Provide a specific period of time)

I understand that I may revoke this "consent to release information" at any time, in writing.

MEDICARE BENEFICIARY INFORMATION AND SIGNATURE:

Beneficiary Signature: Date signed: 

Note: If the beneficiary is incapacitated, the submitter of this document will need to include documentation

establishing the authority of the individual signing on the beneficiary's behalf. Please visit

littps:,/go.cms.gov/cobro for further instructions.

Medicare ID (The number on your Medicare card.): 

Date of Injury/Illness: 

Case 3:20-cv-05826-TKW-HTC Document 1-1 Filed 09/17/20 Page 26 of 37
Social Security Administration Form Approved

Consent for Release of Information OMB No. 0960-0566

I nstructionsfor Using this Form

Complete this form only if you want us to give information or records about you, a minor, or a legally incompetent adult, to an

i ndividual or group (for example, a doctor or an insurance company). If you are the natural or adoptive parent or legal guardian,

acting on behalf of a minor child, you may complete this form to release only the minor's non-medical records. We may charge a

fee for providing information unrelated to the administration of a program under the Social Security Act.

NOTE: Do not use this form to:

• Request the release of medical records on behalf of a minor child. Instead, visit your local Social Security office or call our tollfree number, 1-800-772-1213 (TTY-1-800-325-0778), or

• Request detailed information about your earnings or employment history. Instead, complete and mail form SSA-7050-F4. You

can obtain form SSA-7050-F4 from your local Social Security office or online at www.ssa,_govionl i ne/ssa-7050.pdf.

How to Complete this Form

We will not honor this form unless all required fields are completed. An asterisk (*) indicates a required field. Also, we will not

honor blanket requests for "any and all records" or the "entire file." You must specify the information you are requesting and you

must sign and date this form. We may charge a fee to release information for non-program purposes.

• Fill in your name, date of birth, and social security number or the name, date of birth, and social security number of the person

to whom the requested information pertains.

• Fill in the name and address of the person or organization where you want us to send the requested information.

• Specify the reason you want us to release the information.

• Check the box next to the type(s) of information you want us to release including the date ranges, where applicable.

• For non-medical information, you, the parent or the legal guardian acting on behalf of a minor child or legally incompetent adult,

must sign and date this form and provide a daytime phone number.

• If you are not the individual to whom the requested information pertains, state your relationship to that person. We may require

proof of relationship.

PRIVACY ACT STATEMENT

Section 205(a) of the Social Security Act, as amended, authorizes us to collect the information requested on this form. We will

use the information you provide to respond to your request for access to the records we maintain about you or to process your

request to release your records to a third party. You do not have to provide the requested information. Your response is

voluntary; however, we cannot honor your request to release information or records about you to another person or organization

without your consent. We rarely use the information provided on this form for any purpose other than to respond to requests for

SSA records information. However, the Privacy Act (5 U.S.C. § 552a(b)) permits us to disclose the information you provide on this

form in accordance with approved routine uses, which include but are not limited to the following:

1.To enable an agency or third party to assist Social Security in establishing rights to Social Security benefits and or coverage;

2.To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and local level;

3.To comply with Federal laws requiring the disclosure of the information from our records; and,

4.To facilitate statistical research, audit, or investigative activities necessary to assure the integrity of SSA programs.

We may also use the information you provide when we match records by computer. Computer matching programs compare our

records with those of other Federal, State, or local government agencies. We use information from these matching programs to

establish or verify a person's eligibility for Federally-funded or administered benefit programs and for repayment of incorrect

payments or overpayments under these programs. Additional information regarding this form, routine uses of information, and

other Social Security programs is available on our Internet website, www.soci alsecurity.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 3 minutes to read the instructions, gather the facts, and answer the questions. SEND

OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social

Security office through SSA's website at www.soci alsecurity.gov. Offices are also listed under U.S. Government agencies

i n your telephone directory or you may call 1-800-772-1213 (TYY 1-800-325-0778). You may send comments on our time

estimate above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only comments relating to our time estimate

to this address, not the completed form.

Form SSA-3288 (11-2016) uf

Destroy Prior Editions

Case 3:20-cv-05826-TKW-HTC Document 1-1 Filed 09/17/20 Page 27 of 37
Social Security 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. **Please complete these fields in case we need to contact you about the consent form).

TO: Social Security Administration

*My Full Name *My Date of Birth *My Social Security Number

(MM/DDNYYY)

I authorize the Social Security Administration to release information or records about me to:

*NAME OF PERSON OR ORGANIZATION: *ADDRESS OF PERSON OR ORGANIZATION:

Joseph B. Stokes, III, Esq. 245 Riverside Avenue

Saalfield Shad, P.A. Suite 400

Jacksonville, FL 32202

*1 want this information released because: Civil Litigation Matter

We may charge a fee to release information for non-program purposes.

*Please release the following information selected from the list below:

Check at least one box. We will not disclose records unless you include date ranges where applicable.

1. D Verification of Social Security Number

2. El Current monthly Social Security benefit amount

3. El Current monthly Supplemental Security Income payment amount

4. El My benefit or payment amounts from date 01/01/2009 to date 

5. El My Medicare entitlement from date to date 

6. El Medical records from my claims 1 folder(s) from date°

/01/2o09 to date 

If you want us to release a minor child's medical records, do not use this form. Instead, contact your local Social

Security office.

7. 0 Complete medical records from my claims folder(s)

8. [1] Other record(s) from my file (We will not honor a request for "any and all records" or "the entire file." You must specify

other records; e.g., consultative exams, award/denial notices, benefit applications, appeals, questionnaires,

doctor reports, determinations.)

Application for Benefits, doctor reports, Consultation Evaluation Reports, questionnaires,

Determinations,appeals,Disability records/start date, and date of entitlement

I am the individual, to whom the requested information or record applies, or the parent or legal guardian of a minor, or the

legal guardian of a legally incompetent adult. I declare under penalty of perjury (28 CFR § 16.41(d)(2004) that I have examined

all the information on this form and it is true and correct to the best of my knowledge. I understand that anyone who knowingly

or willfully seeking or obtaining access to records about another person under false pretenses is punishable by a fine of up to

$5,000. I also understand that I must pay all applicable fees for requesting information for a non-program-related purpose.

*Signature: *Date:

**Address: **Daytime Phone:

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

Witnesses must sign this form ONLY if the above signature is by mark (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 2.Signature of witness

Address(Number and street,City,State, and Zip Code) Address(Number and street,City,State, and Zip Code)

Form SSA-3288 (11-2016) uf

Case 3:20-cv-05826-TKW-HTC Document 1-1 Filed 09/17/20 Page 28 of 37
Filing # 112980208 E-Filed 09/08/2020 10:50:20 AM

IN THE CIRCUIT COURT, FIRST

JUDICIAL CIRCUIT, IN AND FOR

ESCAMBIA COUNTY, FLORIDA

CASE NO.: 2020-CA-000976

DIVISION: F

ALLISON BOURN,

Plaintiff,

vs.

TARGET CORPORATION,

a foreign profit corporation,

Defendant.

NOTICE OF SERVICE OF DEFENDANT'S

FIRSTINTERROGATORIES TOPLAINTIFF ALLISON BOURN

Defendant, Target Corporation, hereby gives notice that Defendant's Interrogatories to

Plaintiff, ALLISON BOURN, numbered one (1) through twenty-eight (28), have been served upon

Plaintiff, c/o Wyatt M. Oakey, Esquire, by Electronic Mail.

CERTIFICATE OF SERVICE

I HEREBY CERTIFY that a true and correct copy of the foregoing has been e-filed with

the Clerk of the Court by using the Florida Courts Portal system and furnished to the following

named addressees via email on this 8th day of September, 2020:

Wyatt M. Oakey, Esquire

Morgan & Morgan, P.A.

220 West Garden Street, 9th Floor

Pensacola, FL 32502

Email: woakey@forthepeople.com,wmoservice@forthepeople.com

Telephone: 850-316-9069

Facsimile: 850-316-9105

Attorneys for Plaintiff

SAALFIELD SHAD, P.A.

/s/ Joseph B. Stokes, III

Case 3:20-cv-05826-TKW-HTC Document 1-1 Filed 09/17/20 Page 29 of 37
JOSEPH B. STOKES, III, ESQUIRE

Florida Bar Number: 897183

Email (Primary) jstokes@saalfieldlaw.com

Email (Secondary) llovein@saalfieldlaw.com,

wdean@saalfieldlaw.com

RUBY JO CATHERINE SMITH, ESQUIRE

Florida Bar Number: 112741

Email (Primary) rjcs@saalfieldlaw.com

245 Riverside Avenue, Suite 400

Jacksonville, FL 32202

904-355-4401 (phone)

904-355-3503 (facsimile)

Attorneys for Defendant

2

Case 3:20-cv-05826-TKW-HTC Document 1-1 Filed 09/17/20 Page 30 of 37
IN THE CIRCUIT COURT, FIRST

JUDICIAL CIRCUIT, IN AND FOR

ESCAMBIA COUNTY, FLORIDA

CASE NO.: 2020-CA-000976

DIVISION:

ALLISON BOURN,

Plaintiff,

vs.

TARGET CORPORATION,

a foreign profit corporation,

Defendant.

DEFENDANT,TARGETCORPORATION'S

NOTICE OFFILING NOTICE OFREMOVAL

Defendant, Target Corporation, by and through its undersigned attorneys, and

pursuant to 28 U.S.C. §1332, §1441, and §1446, hereby gives notice that it has this

date filed with the U.S. District Court for the Northern District of Florida, Pensacola

Division, a Notice of Removal. A copy of the Notice of Removal (without Exhibits)

is attached hereto as Exhibit "A."

CERTIFICATE OFSERVICE

IHEREBY CERTIFY that a true and correct copy of the foregoing has been

e-filed with the Clerk of the Court by using the Florida Courts Portal system and

furnished to the following named addressees via email on this 17th day of September,

2020:

Wyatt M. Oakey, Esquire

Morgan & Morgan, P.A.

220 West Garden Street, 9th Floor

Filing # 113509231 E-Filed 09/17/2020 10:20:10 AM Case 3:20-cv-05826-TKW-HTC Document 1-1 Filed 09/17/20 Page 31 of 37
Pensacola, FL 32502

Email: woakey@forthepeople.com,wmoservice@forthepeople.com

Telephone: 850-316-9069

Facsimile: 850-316-9105

Attorneys for Plaintiff

SAALFIELD SHAD, P.A.

/s/ Joseph B. Stokes, III

JOSEPH B. STOKES, III, ESQUIRE

Florida Bar Number: 897183

Email (Primary) jstokes@saalfieldlaw.com

Email (Secondary) llovein@saalfieldlaw.com;

wdean@saalfieldlaw.com

245 Riverside Avenue, Suite 400

Jacksonville, FL 32202

904-355-4401 (phone)

904-355-3503 (facsimile)

Attorneys for Defendant

2

Case 3:20-cv-05826-TKW-HTC Document 1-1 Filed 09/17/20 Page 32 of 37
IN THE UNITED STATES DISTRICT COURT

FOR THE NORTHERN DISTRICT OF FLORIDA

PENSACOLA DIVISION

ALLISON BOURN,

Plaintiff,

vs.

TARGET CORPORATION, a Foreign

Profit Corporation,

Defendants.

CASE NO.:

DEFENDANTTARGET CORPORATION'S NOTICE OFREMOVAL

Defendant Target Corporation (hereinafter "Defendant"), by and through its

undersigned attorneys and pursuant to 28 U.S.C. § 1446, files with this Court a

Notice of Removal of the above-captioned matter from the First Judicial Circuit, in

and for Escambia County, Florida. In support of the removal of this action,

Defendant states as follows:

1. Plaintiff Allison Bourn has filed a civil action in the Circuit Court, First

Judicial Circuit, in and for Escambia County, Florida, Case No. 20-CA-00976, for

claimed injuries allegedly due to an incident in which Ms. Bourn allegedly slipped

and fell on the Defendant's premises on December 22, 2019 in Escambia County,

Florida. True and correct copies of all process and pleadings served by or upon

Defendant, as provided by 28 U.S.C. § 1446(a), are attached hereto as Exhibit "A".

EXHIBIT

.o

a

Case 3:20-cv-05826-TKW-HTC Document 1-1 Filed 09/17/20 Page 33 of 37
2. Defendant removes this action on the basis of diversity jurisdiction

pursuant to 28 U.S.C. § 1332 and § 1441.

3. At the time of the incident alleged in Plaintiff's Complaint, Plaintiff was a

citizen and resident of Escambia County, Florida. (Complaint ¶2).

4. Defendant Target Corporation, at all relevant times, has been a domiciliary

of the State of Minnesota, is incorporated in Minnesota, and has its principal place

of business in Minnesota.

5. The Complaint alleges the damages "exceed Thirty Thousand Dollars

($30,000.00)." (Complaint ¶1). Plaintiff's claimed damages include: bodily injury,

pain and suffering, disability, disfigurement, mental anguish, permanent and

significant scarring, mental anguish, loss of capacity for enjoyment of life,

hospitalization expenses, medical and nursing care and treatment, loss of earnings,

loss of ability to earn money, and aggravation of a previously existing condition.

(Complaint ¶11). Plaintiff claims these losses are either permanent or continuing

and will continue to be suffered in the future. (Id.).

6. Prior to the lawsuit being filed, Plaintiff provided a demand to

Defendant on April 23, 2020, attached hereto as Exhibit "B." The estimated cost of

Plaintiff's future medical treatment, as determined by Karen Shelton, RN, of

ProjectWorks Cost Projections, is allegedly $133,248.89. In addition, Plaintiff

demanded 47,680.00 for her past pain and suffering, and $1,547,600.00 for future

2

Case 3:20-cv-05826-TKW-HTC Document 1-1 Filed 09/17/20 Page 34 of 37
pain and suffering. Based on current information and belief, the Plaintiff has treated

at West Florida Hospital, Emerald Coast Medical Solutions, Innovative Open MRI

of Pensacola, and Panhandle Orthopedics. Not all of Plaintiff's medical bills have

been obtained by Defendant. Defendant is only in possession of bills from West

Florida Hospital ($23,411.00) and Emerald Coast Medical Solutions ($3,195.00) for

a total of 26,606.00, attached hereto as Exhibit "C."

7. According to the Plaintiff's medical records from Panhandle

Orthopedics, dated February 26, 2020, (attached hereto as Exhibit "D") Dr. Michael

Gilmore determined the Plaintiff had a left medial meniscus tear that required

surgery. The Plaintiff planned to move forward with the surgery, however it is

unknown to Defendant at this time if the Plaintiff has done so. Dr. Gilmore also

opined the Plaintiff's sacroiliac pain would require further treatment, with the

options of NSAIDS, physical therapy, cortisone injections, and radiofrequency

denervation.

8. As listed above, Plaintiff's current known medical expenses are

$26,606.00. Her future medical expenses, according to Karen Shelton, RN, are

allegedly 133,248.89. Her claimed past and future pain and suffering total

$1,595,280.00. All combined, the Plaintiff is seeking

75,000 jurisdictional requirement.

3

1,755,134.89, well above the

Case 3:20-cv-05826-TKW-HTC Document 1-1 Filed 09/17/20 Page 35 of 37
9. Defendant has filed this Notice of Removal within thirty (30) days of

service of Plaintiff's Complaint on August 19, 2020. Therefore, this Notice of

Removal is timely.

10. Pursuant to 28 U.S.C. § 1446(d), Defendant has given written notice of

this removal to all parties and has filed a copy of this Notice of Removal in the

Circuit Court, First Judicial Circuit, in and for Escambia County, Florida.

1 1. The United States District Court for the Northern District of Florida,

Pensacola Division, encompasses the location of the State Court action. Thus,

Defendant may properly remove the State Court action to this District Court pursuant

to 28 U.S.C. §1441(a).

12. The amount in controversy in this case is greater than S75,000.00

exclusive of interest and costs, and there is complete diversity between the parties.

Therefore, this United States District Court has original jurisdiction pursuant to 28

U.S.C. §1332.

13. Pursuant to the rules of this Court, Defendant has submitted the S400.00

filing fee.

WHEREFORE, the Defendant respectfully requests that this Court accept the

removal of this action from the Circuit Court, First Judicial Circuit, in and for

Escambia County, Florida.

4

Case 3:20-cv-05826-TKW-HTC Document 1-1 Filed 09/17/20 Page 36 of 37
CERTIFICATE OFSERVICE

IHEREBY CERTIFY that a true and correct copy of the foregoing has been

e-filed with the Clerk of the Court by using the Florida Courts Portal system and

furnished to the following named addressees via email on this 17th day of September,

2020:

Wyatt M. Oakey, Esquire

Morgan & Morgan, P.A.

220 West Garden Street, 9th Floor

Pensacola, FL 32502

Email: woakey@forthepeople.com; wmoservice@forthepeople.com

Telephone: 850-316-9069

Facsimile: 850-3 16-9 105

Attorneys for Plaintiff

SAALFIELD SHAD, P.A.

/s/ Joseph B. Stokes, III

JOSEPH B. STOKES, III, ESQUIRE

Florida Bar Number: 897183

Email (Primary) jstokes@saalfieldlaw.com

Email (Secondary) llovein@saalfieldlaw.com;

wdean@saalfieldlaw.com

245 Riverside Avenue, Suite 400

Jacksonville, FL 32202

904-355-4401 (phone)

904-355-3503 (facsimile)

Attorneys for Defendant

5

Case 3:20-cv-05826-TKW-HTC Document 1-1 Filed 09/17/20 Page 37 of 37