FILED: QUEENS COUNTY CLERK 06/27/ :14 PM INDEX NO /2016 NYSCEF DOC. NO. 43 RECEIVED NYSCEF: 06/27/2018

Transcription

1 SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF QUEENS X VOLODYMYR VEHNER, -against-. RESPONSE TO Plamtiff ' POST-DEPOSITION DEMANDS THE MOUNT SINAI HOSPITAL and THE MOUNT SINAI MEDICAL CENTER, INC., Index No /2016 Defendants X PLEASE TAKE NOTICE, that Plaintiff by his attorneys, SIEGEL 4 COONERTY, LLP., as and for a response to Defendants' Post-Deposition Demands dated December 15, 2017 alleges upon information and belief, as follows: 1. Plaintiff is unaware of the last known address of Serhey Sulima. 2. Upon information and belief plaintiff is no longer in possession of additional licenses. 3. Plaintiff does not have copies unpaid medical bills. 4. Annexed hereto are copies of plaintiff's personal tax returns for tax years 2011 to Annexed hereto are copies of plaintiff's corporate tax returns for Rianna, LLC for tax years 2016 to the present. 6. Plaintiff was prescribed topical pain medication, Diclofenac-Sodium 1% gel. 7. Annexed hereto are authorizations for the following a. Annexed hereto is an authorization for the release of employment records from ETS Contracting, Inc., 160 Clay Street, Brooklyn, New York (Local 78 contractor identified by plaintiff as "ATS").

2 b. Annexed hereto is an authorization for the release of employment records from ABC Corporation Contracting, Inc., th Avenue, Astoria, NY c. Annexed hereto is an authorization for the release of employment records from Milcon Construction Corp., 142 Dale Street, West Babylon, NY d. Annexed hereto is an authorization for the release of employment records from 123 Construction, th Avenue, Flushing, NY e. Annexed hereto is an authorization for the release of union records records from Mason Tenders' District Council of Greater New York and Long Island, 520 8th Avenue, Room 600, New York, New York f. Annexed hereto is an authorization for the release of pharmacy records from CVS Pharmacy, Metropolitan Ave Ridgewood, NY g. Annexed hereto is an authorization for the release of medical records from ENT specialist, Nelson Alcaraz, M.D., Ear Nose Throat Associates, NY 11355, Main Street, Flushing, New York h. Annexed hereto is an authorization for the release of medical records from Orthopedic surgeon, Maxim Tyorkin, M.D., Queens Boulevard, Forest Hills, New York i. Annexed hereto is an authorization for Dr. Michael Robert Jurkowich, nd Avenue, New York, New York j. Annexed hereto is an authorization for the release of New York City Human Resources Administration (Supplemental Nutrition Assistance Program (food stamp benefits) records from Human Resources Administration, Office of Legal

3 Affairs/Subpoena Unit, 4 World Trade Center, 150 Greenwich Street, 38th floor New York, New York k. Annexed hereto is an authorization for the release of New York State Office of Temporary and Disability Assistance (Supplemental Nutrition Assistance Program (food stamp benefits), 40 North Pearl Street Albany, NY Annexed hereto is an authorization for the release of records from Retro Fitness, 6545 Otto Road, New York, New York m. Annexed hereto is an authorization for the release of records from Force Fitness Club, 6303 Fresh Pond Road, Ridgewood, NY n. Annexed hereto are plaintiff's Internal Revenue Service personal tax returns for tax years 2012 to 2016). 0. Annexed hereto are plaintiff's Internal Revenue Service corporate tax returns for Rianna, LLC for tax year p. Annexed hereto is an authorization for the release of plaintiff's personal and corporate tax returns, filings and other records for tax years 2012 to the present from Tax Integrity, LLC (Olga Zelenkova), 1724 Bath Avenue, Brooklyn, New York Dated: New York, New York June 27, 2018 Yours etc., Sean C(onerty SIEGEL P Attorneys for Plaintiff, VOLODYMYR VEHNER 419 Park Avenue South, Suite 700 New York, New York 10016

4 Telephone Number: Our File No. SC TO: David S. Yohay, Esq. LANDMAN CORSI BALLAINE & FORD, P.C. Attorneys for Defendants 120 Broadway, 27th Floor New York, New York Telephone Number:

5 POWER OF ATTORNEY I a o / tn r tån8/~ Do hereby a poi : SIEGEL & COONERTY, LLP., with offices at 419 Park Avenue South, 7"' Floor, New York, NY 10016, my attorneys-in-fact to act (each agent may act separately) in my name, place and stead in any way which I myself could do, if I were personally present to execute any and all required documentation including but not limited to, HIPAA medical records authorization forms pursuant to NY Public Health Law 18(1)(g) as amended 10/26/04, General authorizations for Insurance, Epiployment, etc., and any other required documentation in connection to my accident of $/3 /&. This power of attorney may be revoked by me at any time. This induce any third party to act hereunder, I hereby agree that any third party receiving a duly executed copy of facsimile of this instrument may act hereunder, and that revocation or termination hereof shall be ineffective as to such third party unless and until actual notice or knowledge of such revocation or termination shall have been received by such third party, and I for myself and for my heirs, executors, legal representatives and assigns, hereby agree to indemnify and hold harmless any such third party from and against any and all claims that may arise against such third party by reason of such third party having relied on the provisions of this instrument. In Witness whereof I have hereunto signed my name this ff day of fap "d 20_(6 ACKNOWLEDGEMENT STATE OF NEW YORK COUNTY OF NEW YORK SS On this 2 day of p/ 20 //, before me the undersigned, personally appeared /I /re er personally known to be or proved to me on the basis of atisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in this capacity, and that by his/her signature on the instrument, the individual, or the person who acted on behalf of the individual, executed the instrument and that such individual made such appearance before the undersigned at New York, New York. N ary SEAN COONERTY NOTARY PUBUC-STATE OF NEW YORK No. 02CO Qualified in Nassau County My Commission Expires March 06, 2018

6 OCA Official Form No.: 960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [This form has been approved by the New York State Department of Health] Patient Name Date of Birth mber VOLODYMYR VEHNER FEBRUARY 4, 1983 Patient Address: th Avenue, 3rd Floor, Ridgewood, NY I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form: In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that: 1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only if I place my initials on the appropriate line in Item 9(a). In the event the health information described below includes any of these types of information, and I initial the line on the box in Item 9(a), I specifically authorize release of such information to the person(s) indicated in Item If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I understand that I have the right to request a list of people who may receive or use my HIV-related information without authorization. If I experience discrimination because of the release or disclosure of HIV-related information, I may contact the New York State Division of Human Rights at (212) or the New York City Commission of Human Rights at (212) These agencies are responsible for protecting my rights. 3. I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization. 4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure. 5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this redisclosure may no longer be protected by federal or state law. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CA RE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).. 7. Name and address of health provider or entity to release this information: ETS Contracting, Inc., 160 Clay Street, Brooklyn, New York Name and address of person(s) or category of person to whom this information will be sent: LANDMAN CORSI BALLAINE & FORD, P.C., 120 Broadway, 27th Floor, New York, NY (a). Specific information to be released: Medical Record from to O Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films, referrals, consults, billing records, insurance records, and records sent to you by other health care providers. X Other: Employment records Include: (Indicate by Initialing) Alcohol/Drug Treatment Mental Health Information HIV-Related Information Authorization to Discuss Health Information (b) OBy initialing here I authorize Initials Name of individual health care provider to discuss my health information with my attorney, or a governmental agency, listed here: 10. Reason for release of information: 11. Date or event on which this authorization will expire: X At request of individual Conclusion of litigation OOther: 12. If not the patient, name of person signing form 13. Authority to sign on behalf of patient Siegel & Coonerty, LLP by Sean Coonerty, Esq. Power of Attorney annexed hereto All items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a copy of the form. Signature of tient or re sentativ orized by law. Date: June 27, 2018 * Human Immunodeficiency irus that sesaids. The New York State Public Health Law protects information which reasonably could identify someone as having HIV symptoms or infection and information regarding a person's contacts.

7 OCA Official Form No.: 960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA (This form has been approved by the New York State Department of Health] Patient Name Date of Birth Social Securit Number VOLODYMYR VEHNER FEBRUARY 4, 1983 Patient Address: th Avenue, 3rd Floor, Ridgewood, NY I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form: In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that: 1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only if I place my initials on the appropriate line in Item 9(a). In the event the health information described below includes any of these types of information, and I initial the line on the box in Item 9(a), I specifically authorize release of such information to the person(s) indicated in Item If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I understand that I have the right to request a list of people who may receive or use my HIV-related information without authorization. If I experience discrimination because of the release or disclosure of HIV-related information, 1 may contact the New York State Division of Human Rights at (212) or the New York City Commission of Human Rights at (212) These agencies are responsible for protecting my rights. 3. I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization. 4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure. 5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this redisclosure may no longer be protected by federal or state law. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CA RE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).. 7. Name and address of health provider or entity to release this information: 19th ABC Corporation Contracting, Inc., Avenue, Astoria, NY , Name and address of person(s) or category of person to whom this information will be sent: LANDMAN CORSI BALLAINE & FORD, P.C., 120 Broadway, 27th Floor, New York, NY (a). Specific information to be released: O Medical Record from to O Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films, referrals, consults, billing records, insurance records, and records sent to you by other health care providers. Include: (Indicate by Initialing) X Other: Employment records Alcohol/Drug Treatment Mental Health Information HIV-Related Information Authorization to Discuss Health Information (b) OBy initialing here I authorize Initials Name of individual health care provider to discuss my health information with my attorney, or a governmental agency, listed here: 10. Reason for release of information: 11. Date or event on which this authorization will expire: X At request of individual Conclusion of litigation OOther: 12. If not the patient, name of person signing form 13. Authority to sign on behalf of patient Siegel & Coonerty, LLP by Sean Coonerty, Esq. Power of Attorney annexed hereto All items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a copy of the form. ' Signatu/p of p t1 re e authorized by law. Date: June 27, 2018 * Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which reasonably could identify someone as symptoms or and information a person's contacts. having HIV infection regarding

8 OCA Official Form No.: 960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [This form has been approved by the New York State Department of Health] Patient Name Date of Birth umber VOLODYMYR VEHNER FEBRUARY 4, 1983 Patient Address: th Avenue, 3rd Floor, Ridgewood, NY I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form: In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that: 1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only if I place my initials on the appropriate line in Item 9(a). In the event the health information described below includes any of these types of information, and I initial the line on the box in Item 9(a), I specifically authorize release of such information to the person(s) indicated in Item If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I understand that I have the right to request a list of people who may receive or use my HIV-related information without authorization. If I experience discrimination because of the release or disclosure of HIV-related information, I may contact the New York State Division of Human Rights at (212) or the New York City Commission of Human Rights at (212) These agencies are responsible for protecting my rights. 3. I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization. 4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure. 5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this redisclosure may no longer be protected by federal or state law. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CA RE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).. 7. Name and address of health provider or entity to release this information: Milcon Construction Corp.,., 142 Dale Street, West Babylon, NY Name and address of person(s) or category of person to whom this information will be sent: LANDMAN CORSI BALLAINE & FORD, P.C., 120 Broadway, 27th Floor, New York, NY (a). Specific information to be released: O Medical Record from to O Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films, referrals, consults, billing records, insurance records, and records sent to you by other health care providers. X Other: Employment records Include: (Indicate by Initialing) Alcohol/Drug Treatment Mental Health Information HIV-Related Information Authorization to Discuss Health Information (b) OBy initialing here I authorize Initials Name of individual health care provider to discuss my health information with my attorney, or a governmental agency, listed here: 10. Reason for release of information: 11. Date or event on which this authorization will expire: X At request of individual Conclusion of litigation OOther: 12. If not the patient, name of person signing form 13. Authority to sign on behalf of patient Siegel & Coonerty, LLP by Sean Coonerty, Esq. Power of Attorney annexed hereto All items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a copy of the form. Signature of p ignt or s orized by law. Date: June 27, 2018 * Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which reasonably could identify someone as symptoms or infection and a person's contacts. having HIV information regarding

9 <~%WJ/ OCA Official Form No.: 960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [This form has been approved by the New York State Department of Health] Patient Name Date of Birth Social Securit mber VOLODYMYR VEHNER FEBRUARY 4, 1983 Patient Address: th Avenue, 3rd Floor, Ridgewood, NY I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form: In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that: 1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and HIV* CONFIDENTIAL RELATED INFORMATION only if I place my initials on the appropriate line in Item 9(a). In the event the health information described below includes any of these types of information, and I initial the line on the box in Item 9(a), I specifically authorize release of such information to the person(s) indicated in Item If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I understand that I have the right to request a list of people who may receive or use my HIV-related information without authorization. If I experience discrimination because of the release or disclosure of HIV-related information, I may contact the New York State Division of Human Rights at (212) or the New York City Commission of Human Rights at (212) These agencies are responsible for protecting my rights. 3. I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization. 4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure. 5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this redisclosure may no longer be protected by federal or state law. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).. 7. Name and address of health provider or entity to release this information: 123 Construction, th Avenue, Flushing, NY Name and address of person(s) or category of person to whom this information will be sent: LANDMAN CORSI BALLAINE & FORD, P.C., 120 Broadway, 27th Floor, New York, NY (a). Specific information to be released: O Medical Record from to O Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films, referrals, consults, billing records, insurance records, and records sent to you by other health care providers. X Other: Employment records Include: (Indicate by Initialing) Alcohol/Drug Treatment Mental Health Information HIV-Related Information Authorization to Discuss Health Information (b) OBy initialing here I authorize Initials Name of individual health care provider to discuss my health information with my attorney, or a governmental agency, listed here: 10. Reason for release of information: 11. Date or event on which this authorization will expire X At request of individual Conclusion of litigation O Other: 12. If not the patient, name of person signing form 13. Authority to sign on behalf of patient Siegel & Coonerty, LLP by Sean Coonerty, Esq. Power of Attorney annexed hereto All items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a copy of the form. Signature of tient or re esentative; horized by law. Date: June 27, 2018 * Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which reasonably could identify someone as symptoms or and a person's contacts. having HIV infection information regarding

10 J) OCA Official Form No.: 960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [This form has been approved by the New York State Department of Health] Patient Name Date of Birth Social Sec i ber VOLODYMYR VEHNER FEBRUARY 4, 1983 Patient Address: th Avenue, 3rd Floor, Ridgewood, NY I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form: In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that: 1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only if I place my initials on the appropriate line in Item 9(a). In the event the health information described below includes any of these types of information, and I initial the line on the box in Item 9(a), I specifically authorize release of such information to the person(s) indicated in Item If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I understand that I have the right to request a list of people who may receive or use my HIV-related information without authorization. If I experience discrimination because of the release or disclosure of HIV-related information, I may contact the New York State Division of Human Rights at (212) or the New York City Commission of Human Rights at (212) These agencies are responsible for protecting my rights. 3. I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization. 4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure. 5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this redisclosure may no longer be protected by federal or state law. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CA RE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).. 7. Name and address of health provider or entity to release this information: Tenders' Mason District Council of Greater New York and Long Island, 520 York, New York Name and address of person(s) or category of person to whom this information will be sent: 8th Avenue, Room 600, New LANDMAN CORSI BALLAINE & FORD, P.C., 120 Broadway, 27th Floor, New York, NY (a). Specific information to be released: O Medical Record from to O Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films, referrals, consults, billing records, insurance records, and records sent to you by other health care providers. X Other: Union records Include: (Indicate by Initialing) Alcohol/Drug Treatment Mental Health Information HIV-Related Information Authorization to Discuss Health Information (b) OBy initialing here I authorize Initials Name of individual health care provider to discuss my health information with my attorney, or a governmental agency, listed here: 10. Reason for release of information: 11. Date or event on which this authorization will expire: X At request of individual Conclusion of litigation OOther: 12. If not the patient, name of person signing form 13. Authority to sign on behalf of patient Siegel & Coonerty, LLP by Sean Coonerty, Esq. Power of Attorney annexed hereto All items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a copy of the form. Signature o patient or re esentativ thorized by law. Date: June 27, 2018 * Human Immunodeficiency irus uses AIDS. The New York State Public Health Law protects information which reasonably could identify someone as symptoms or and a person's contacts. having HIV infection information regarding

11 OCA Official Form No.: 960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [This form has been approved by the New York State Department of Health] Patient Name Date of Birth Social Security Number VOLODYMYR VEHNER FEBRUARY 4, 1983 Patient Address: th Avenue, 3rd Floor, Ridgewood, NY I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form: In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that: 1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only if I place my initials on the appropriate line in Item 9(a). In the event the health information described below includes any of these types of information, and I initial the line on the box in Item 9(a), I specifically authorize release of such information to the person(s) indicated in Item If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I understand that I have the right to request a list of people who may receive or use my HIV-related information without authorization. If I experience discrimination because of the release or disclosure of HIV-related information, I may contact the New York State Division of Human Rights at (212) or the New York City Commission of Human Rights at (212) These agencies are responsible for protecting my rights. 3. I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization. 4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure. 5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this redisclosure may no longer be protected by federal or state law. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).. 7. Name and address of health provider or entity to release this information: CVS Pharmacy, Metropolitan Ave Ridgewood, NY Name and address of person(s) or category of person to whom this information will be sent: LANDMAN CORSI BALLAINE & FORD, P.C., 120 Broadway, 27th Floor, New York, NY (a). Specific information to be released: O Medical Record from to O Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films, referrals, consults, billing records, insurance records, and records sent to you by other health care providers. X Other: Pharmacy records Include: (Indicate by Initialing) Alcohol/Drug Treatment Mental Health Information HIV-Related Information Authorization to Discuss Health Information (b) OBy initialing here I authorize Initials Name of individual health care provider to discuss my health information with my attorney, or a governmental agency, listed here: 10. Reason for release of information: 11. Date or event on which this authorization will expire: X At request of individual Conclusion of litigation OOther: 12. If not the patient, name of person signing form 13. Authority to sign on behalf of patient Siegel & Coonerty, LLP by Sean Coonerty, Esq. Power of Attorney annexed hereto All items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a copy of the form. re' Signature otatient or re esentative u horizid by law. Date: June 27, 2018 * Human Immunodeficiency Virus tha uses AIDS. The New York State Public Health Law protects information which reasonably could identify someone as symptoms or and a person's contacts. having HIV infection information regarding

12 OCA Official Form No.: 960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [This form has been approved by the New York State Department of Health] Patient Name Date of Birth er VOLODYMYR VEHNER FEBRUARY 4, 1983 Patient Address: th Avenue, 3rd Floor, Ridgewood, NY 113 I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form: In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that: 1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only if I place my initials on the appropriate line in Item 9(a). In the event the health information described below includes any of these types of information, and I initial the line on the box in Item 9(a), I specifically authorize release of such information to the person(s) indicated in Item If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I understand that I have the right to request a list of people who may receive or use my HIV-related information without authorization. If I experience discrimination because of the release or disclosure of HIV-related information, I may contact the New York State Division of Human Rights at (212) or the New York City Commission of Human Rights at (212) These agencies are responsible for protecting my rights. 3. I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization. 4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure. 5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this redisclosure may no longer be protected by federal or state law. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CA RE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).. 7. Name and address of health provider or entity to release this information: Nelson Alcaraz, M.D., Ear Nose Throat Associates, NY 11355, Main Street, Flushing, New York Name and address of person(s) or category of person to whom this information will be sent: LANDMAN CORSI BALLAINE & FORD, P.C., 120 Broadway, 27th Floor, New York, NY (a). Specific information to be released: OOther: X Medical Record from 8/3/16 to present O Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films, referrals, consults, billing records, insurance records, and records sent to you by other health care providers. Include: (Indicate by Initialing) Alcohol/Drug Treatment Mental Health Information HIV-Related Information Authorization to Discuss Health Information (b) OBy initialing here I authorize Initials Name of individual health care provider to discuss my health information with my attorney, or a governmental agency, listed here: 10. Reason for release of information: 11. Date or event on which this authorization will expire: X At request of individual Conclusion of litigation O Other: 12. If not the patient, name of person signing form 13. Authority to sign on behalf of patient Siegel & Coonerty, LLP by Sean Coonerty, Esq. Power of Attorney annexed hereto All items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a copy of the form. r' Signature df patient or eifresentati e authorized by law. Date: June 27, 2018 * Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which reasonably could identify someone as symptoms or and information a person's contacts, having HIV infection regarding

13 s ti OCA Official Form No.: 960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [This form has been approved by the New York State De artment of Health] Patient Name Date of Birth umber VOLODYMYR VEHNER FEBRUARY 4, 1983 Patient Address: th Avenue, 3rd Floor, Ridgewood, NY 113 I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form: In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that: 1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only if I place my initials on the appropriate line in Item 9(a). In the event the health information described below includes any of these types of information, and I initial the line on the box in Item 9(a), I specifically authorize release of such information to the person(s) indicated in Item If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I understand that I have the right to request a list of people who may receive or use my HIV-related information without authorization. If I experience discrimination because of the release or disclosure of HIV-related information, I may contact the New York State Division of Human Rights at (212) or the New York City Commission of Human Rights at (212) These agencies are responsible for protecting my rights. 3. I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization. 4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure. 5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this redisclosure may no longer be protected by federal or state law. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CA RE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).. 7. Name and address of health provider or entity to release this information: Maxim Tyorkin, M.D., Queens Boulevard, Forest Hills, New York Name and address of person(s) or category of person to whom this information will be sent: LANDMAN CORSI BALLAINE & FORD, P.C., 120 Broadway, 27th Floor, New York, NY (a). Specific information to be released: OOther: X Medical Record from 8/3/16 to present O Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films, referrals, consults, billing records, insurance records, and records sent to you by other health care providers. Include: (Indicate by Initialing) Alcohol/Drug Treatment Mental Health Information HIV-Related Information Authorization to Discuss Health Information (b) OBy initialing here I authorize Initials Name of individual health care provider to discuss my health information with my attorney, or a governmental agency, listed here: 10. Reason for release of information: 1 1. Date or event on which this authorization will expire: X At request of individual Conclusion of litigation OOther: 12. If not the patient, name of person signing form 13. Authority to sign on behalf of patient Siegel & Coonerty, LLP by Sean Coonerty, Esq. Power of Attorney annexed hereto All items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a copy of the form. Signature f patient o epresenta y authorized by law. Date: June 27, 2018 * Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which reasonably could identify someone as having HIV symptoms or infection and Information regarding a person's contacts.

14 OCA Official Form No.: 960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [This form has been approved by the New York State Department of Health] Patient Name Date of Birth er VOLODYMYR VEHNER FEBRUARY 4, 1983 Patient Address: th Avenue, 3rd Floor, Ridgewood, NY 113 I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form: In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that: 1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only if I place my initials on the appropriate line in Item 9(a). In the event the health information described below includes any of these types of information, and I initial the line on the box in Item 9(a), I specifically authorize release of such information to the person(s) indicated in Item If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I understand that I have the right to request a list of people who may receive or use my HIV-related information without authorization. If I experience discrimination because of the release or disclosure of HIV-related information, I may contact the New York State Division of Human Rights at (212) or the New York City Commission of Human Rights at (212) These agencies are responsible for protecting my rights. 3. I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization. 4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure. 5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this redisclosure may no longer be protected by federal or state law. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).. 7. Name and address of health provider or entity to release this information: 72nd Dr. Michael Robert Jurkowich, Avenue, New York, New York Name and address of person(s) or category of person to whom this information will be sent: LANDMAN CORSI BALLAINE & FORD, P.C., 120 Broadway, 27th Floor, New York, NY (a). Specific information to be released: OOther: X Medical Record from 8/3/16 to present O Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films, referrals, consults, billing records, insurance records, and records sent to you by other health care providers. Include: (Indicate by Initialing) Alcohol/Drug Treatment Mental Health Information HIV-Related Information Authorization to Discuss Health Information (b) OBy initialing here I authorize Initials Name of individual health care provider to discuss my health information with my attorney, or a governmental agency, listed here: 10. Reason for release of information: 11. Date or event on which this authorization will expire: X At request of individual Conclusion of litigation OOther: 12. If not the patient, name of person signing form 13. Authority to sign on behalf of patient Siegel & Coonerty, LLP by Sean Coonerty, Esq. Power of Attorney annexed hereto All items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a copy of the form. Signature atient or / esent tiv a thor zed by law. Date: June 27, 2018 * Human Immunodeficien uses AIDS. The New York State Public Health Law protects information which reasonably could identify someone as symptoms or and a person's contacts. having HIV infection information regarding

15 r.ji OCA Official Form No.: 960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [This form has been approved by the New York State Department of Health] Patient Name Date of Birth Social Security Number VOLODYMYR VEHNER FEBRUARY 4, 1983 Patient Address: th Avenue, 3rd Floor, Ridgewood, NY 11 I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form: In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that: 1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only if I place my initials on the appropriate line in Item 9(a). In the event the health information described below includes any of these types of information, and I initial the line on the box in Item 9(a), I specifically authorize release of such information to the person(s) indicated in Item If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I understand that I have the right to request a list of people who may receive or use my HIV-related information without authorization. If I experience discrimination because of the release or disclosure of HIV-related information, I may contact the New York State Division of Human Rights at (212) or the New York City Commission of Human Rights at (212) These agencies are responsible for protecting my rights. 3. I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization. 4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure. 5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this redisclosure may no longer be protected by federal or state law. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CA RE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).. 7. Name and address of health provider or entity to release this information: Human Resources Administration, Office of Legal Affairs/Subpoena Unit, 4 World Trade Center, 150 Greenwich Street, 38th floor, New York, New York Name and address of person(s) or category of person to whom this information will be sent: LANDMAN CORSI BALLAINE & FORD, P.C., 120 Broadway, 27th Floor, New York, NY (a). Specific information to be released: Medical Record from to O Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films, referrals, consults, billing records, insurance records, and records sent to you by other health care providers. Include: (Indicate by Initialing) XX Other: New York City Human Resources Administration (Supplemental Nutrition Assistance Alcohol/Drug Treatment Program (food stamp benefits) records Mental Health Information HIV-Related Information Authorization to Discuss Health Information (b) OBy initialing here I authorize Initials Name of individual health care provider to discuss my health information with my attorney, or a governmental agency, listed here: 10. Reason for release of information: 11. Date or event on which this authorization will expire: X At request of individual Conclusion of litigation O Other: 12. If not the patient, name of person signing form 13. Authority to sign on behalf of patient Siegel & Coonerty, LLP by Sean Coonerty, Esq. Power of Attorney annexed hereto All items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a copy of the form. Signature f patient or f resentatiy authorized by law. Date: June 27, 2018 * Human ImmunÀficiency Irus t fauses AIDS. The New York State Public Health Law protects information which reasonably could identify someone as symptoms or infection and a person's contacts. having HIV information regarding

16 OCA Official Form No.: 960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [This form has been approved by the New York State Department of Health] Patient Name Date of Birth mber VOLODYMYR VEHNER FEBRUARY 4, 1983 Patient Address: th Avenue, 3rd Floor, Ridgewood, NY I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form: In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that: 1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only if I place my initials on the appropriate line in Item 9(a). In the event the health information described below includes any of these types of information, and I initial the line on the box in Item 9(a), I specifically authorize release of such information to the person(s) indicated in Item If 1 am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I understand that I have the right to request a list of people who may receive or use my HIV-related information without authorization. If I experience discrimination because of the release or disclosure of HIV-related information, 1 may contact the New York State Division of Human Rights at (212) or the New York City Commission of Human Rights at (212) These agencies are responsible for protecting my rights. 3. I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization. 4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure. 5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this redisclosure may no longer be protected by federal or state law. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).. 7. Name and address of health provider or entity to release this information: New York State Office of Temporary and Disability Assistance, 40 North Pearl Street Albany, NY Name and address of person(s) or category of person to whom this information will be sent: LANDMAN CORSI BALLAINE 4 FORD, P.C., 120 Broadway, 27th Floor, New York, NY (a). Specific information to be released: O Medical Record from to O Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films, referrals, consults, billing records, insurance records, and records sent to you by other health care providers. XX Other: New York State Office of Temporary and Include: (Indicate by Initialing) Disability Assistance (Supplemental Nutrition Alcohol/Drug Treatment Assistance Program (food stamp benefits) records Mental Health Information HIV-Related Information Authorization to Discuss Health Information (b) OBy initialing here I authorize Initials Name of individual health care provider to discuss my health information with my attorney, or a governmental agency, listed here: 10. Reason for release of information: 11. Date or event on which this authorization will expire: X At request of individual Conclusion of litigation OOther: 12. If not the patient, name of person signing form 13. Authority to sign on behalf of patient Siegel & Coonerty, LLP by Sean Coonerty, Esq. Power of Attorney annexed hereto All items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a copy of the form. ~W Date: June 27, 2018 Signature (f patient or resentati ' authorized bylaw. t * Human Immunodeficiency Virus thitf causes AIDS. The New York State Public Health Law protects information which reasonably could identify someone as symptoms or infection and a person's contacts. having HIV information regarding

17 OCA Official Form No.: 960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [This form has been approved by the New York State Department of Health] Patient Name Date of Birth Social Securit Number VOLODYMYR VEHNER FEBRUARY 4, 1983 Patient Address: th Avenue, 3rd Floor, Ridgewood, NY 113 I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form: In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that: 1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only if I place my initials on the appropriate line in Item 9(a). In the event the health information described below includes any of these types of information, and I initial the line on the box in Item 9(a), I specifically authorize release of such information to the person(s) indicated in Item If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I understand that I have the right to request a list of people who may receive or use my HIV-related information without authorization. If I experience discrimination because of the release or disclosure of HIV-related information, I may contact the New York State Division of Human Rights at (212) or the New York City Commission of Human Rights at (212) These agencies are responsible for protecting my rights. 3. I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization. 4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure. 5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this redisclosure may no longer be protected by federal or state law. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).. 7. Name and address of health provider or entity to release this information: Retro Fitness, 6545 Otto Road, New York, New York Name and address of person(s) or category of person to whom this information will be sent: LANDMAN CORSI BALLAINE & FORD, P.C., 120 Broadway, 27th Floor, New York, NY (a). Specific information to be released: D Medical Record from to D Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films, referrals, consults, billing records, insurance records, and records sent to you by other health care providers. X Other: Membership records Include: (Indicate by Initialing) Alcohol/Drug Treatment Mental Health Information HIV-Related Information Authorization to Discuss Health Information (b) DBy initialing here I authorize Initials Name of individual health care provider to discuss my health information with my attorney, or a governmental agency, listed here: 10. Reason for release of information: 11. Date or event on which this authorization will expire: X At request of individual Conclusion of litigation DOther: 12. If not the patient, name of person signing form 13. Authority to sign on behalf of patient Siegel & Coonerty, LLP by Sean Coonerty, Esq. Power of Attorney annexed hereto All items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a copy of the form. Signature atient or e ese utlibrized by law. Date: June 27, 2018 * Human Immu y Y sesaids. The New York State Public Health Law protects information which reasonably could identify someone as having HIV symptoms or infection and information regarding a person's contacts.

18 ½ OCA Official Form No.: 960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [This form has been approved by the New York State Department of Health] Patient Name Date of Birth Social Securit Number VOLODYMYR VEHNER FEBRUARY 4, 1983 Patient Address: th Avenue, 3rd Floor, Ridgewood, NY I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form: In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that: 1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only if I place my initials on the appropriate line in Item 9(a). In the event the health information described below includes any of these types of information, and I initial the line on the box in Item 9(a), I specifically authorize release of such information to the person(s) indicated in Item If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I understand that I have the right to request a list of people who may receive or use my HIV-related information without authorization. If I experience discrimination because of the release or disclosure of HIV-related information, I may contact the New York State Division of Human Rights at (212) or the New York City Commission of Human Rights at (212) These agencies are responsible for protecting my rights. 3. I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization. 4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure. 5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this redisclosure may no longer be protected by federal or state law. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CA RE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).. 7. Name and address of health provider or entity to release this information: Force Fitness Club, 6303 Fresh Pond Road, Ridgewood, NY Name and address of person(s) or category of person to whom this information will be sent: LANDMAN CORSI BALLAINE & FORD, P.C., 120 Broadway, 27th Floor, New York, NY (a). Specific information to be released: O Medical Record from to O Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films, referrals, consults, billing records, insurance records, and records sent to you by other health care providers. Xx Other: Membership records Include: (Indicate by Initialing) Alcohol/Drug Treatment Mental Health Information HIV-Related Information Authorization to Discuss Health Information (b) OBy initialing here I authorize Initials Name of individual health care provider to discuss my health information with my attorney, or a governmental agency, listed here: 10. Reason for release of information: 11. Date or event on which this authorization will expire: X At request of individual Conclusion of litigation O Other: 12. If not the patient, name of person signing form 13. Authority to sign on behalf of patient Siegel & Coonerty, LLP by Sean Coonerty, Esq. Power of Attorney annexed hereto All items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a copy of the form. Signature patient or r resentativy authorized by law. Date: June 27, 2018 * Human Immunodeficiency Irus th auses AIDS. The New York State Public Health Law protects information which reasonably could identify someone as symptoms or and a person's contacts. having HIV infection information regarding

19

20 , Request for Copy of Tax Return (Rev.September2013) OMB No Departmentof the Treasury InternalRevenueService A Request may be rejected if the form is incomplete or illegible. 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 Retum, or you can quickly request transcripts by using our automated self-help service tools. Please visit us at IRS.gov and click on "Order a Return or Account Transcript" or call a Name shown on tax return. If a joint return, enter the name shown first. 1b First social security number on tax return, individual taxpayer identification number, or * " instructions) ¼l n e r eder 2a If a joint re m, nter spouse's name shown on tax return. 2b. dividual taxpayer identification number if joint tax return 3 Current name, address (including apt., room, or suite no.), city, state, and ZIP code (see instructions) ~env~ 9' /- I88 /.& ~ /i36w 4 Previous address shown on the last return filed if different fro 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. < C'. a~zn Parsi ci//aine A No ~pi. umidps/ Caution.lf the tax return is being mailed to a third party, ensure that you have fiited in lines 6 and 7 before signing. and date the form once you / c have tilled in these linea Completing these steps helps to protect your privacy. Once the IRS discloses your tax return to the third party listed on line 3$ the IRS has no control over what the third party does with the information. if you would like to iimit the third party's authority to disclose your return +~gg information, you can specify this iimitation 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 W Note. if the copies must be certified for court or administrative proceedings, check here 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 J.- ó/ cs)-d/ 2..,2.-o/ 3 2^>/ Y )/f 8 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. Treasury." Enter your SSN, ITIN, or EIN and "Form 4506 request" on your check or money order. a Cost for each return $ /)- b Number of returns requested on line c Total cost. Multiply line 8a by line 8b $ 0- OO 9 If we cannot find the tax return, we will refund the fee. If the refund should go to the third party listed on line 5, check here..... Caution. Do not sign this form unless all applicable lines have been completed. Signature of taxpayer(s). I declare that I am either the taxpayer whose name is shown on line l a 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, partner, guardian, tax matters partner, executor, receiver, administrator, stee, or party other than the taxpayer, I certify that I have the authority to execute Form 4506 on behalf of the taxpayer. Note. For tax returns b n sent to a third party, this form must be received within 120 days of the signature date. Sign V signature (see instru ns) Date Here ) Title (if line la above is a corporation, partnership,estate, or trust) Phone number of taxpayer on line 1a or 2a 99 IB 3W Y88whV Spouse's signature For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No E Form 4606 (Rsv ) Date

21 Request for Copy of Tax Return (Rev.September2013) OMB No Departmentof the Treasury k Request may be rejected if the form is incomplete or illegible. RevenueService 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 "Order a Return or Account Transcript" or call a Name shown on tax return. If a joint return, enter the name shown first. 1b First social security number on tax return, individual taxpayer identification number, or employer identi i ctions) a~na 2a If a joint return, enter spouse's name shown on tax return. 2b Second so I taxpayer I return 3 Current name, address (including apt., room, or suite no.), city, state, and ZIP code (see instructions) +8' 7A'3 re 4 Previous address shown on the last return d if different from lined (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. Caution. if the tax return is being mailed to a third party, ensure that you have filled in fines 6 and 7 before signing. Sign and date the form once you have titled in these lines. Completing these steps helps to protect your privacy. Once the irs discloses your tax return to the third party listed on line 5, the IRS has no control over what the third party does with the information. if you would like to limit the third party's authority to disclose your return information, you can specify this limitation in your written agreement with the third party. 6 Tax return requested. Form 1040, 1120, 941, etc. and all attachments as originally submitted to the IRS, including Form(s) W-2, schedules, or amended returns. Copies of Forms 1040, 1040A, and 1040EZ are generally available for 7 years from filing before they are destroyed by law. Other returns may be available for a longer period of time. Enter only one return number. If you need more than one type of return, you must complete another Form W Note. if the copies must be certified for court or administrative proceedings, check here 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 Za/ 8 Fee. There is a 850 fee for each return requested. Full payment must be included with your request.or it will be rejected. Make your check or money order payable to "United States Treasury." Enter your SSN, ITIN, or EIN and "Form 4506 request" on your check or money order. a Cost for each retum $ b Number of returns requested on line / c Total cost. Multiply line 8a by line $ 9 If we cannot find the tax return, we will refund the fee. If the refund should go to the third party listed on line 5, check here..... Caution. Do not sign this form unless all applicable lines have been completed. Signature of taxpayer(s). I declare that I am either the taxpayer whose name is shown on line 1a or 2a, or a person authorized to obtain the tax return requested. If the request applies to a j nt return, at least one spouse must sign. If signed by a corporate officer, partner, guardian, tax matters partner, executor, receiver, administrator, tru e, or party other than the taxpayer, I certify that I have the authority to execute Form 4506 on behalf of the taxpayer. Note. For tax returns bein ent to a third party, this form must be received within f 20 days of the signature date. Phone number la or 2a of taxpayer on line Sign signature (seeinstru ' i ns) Date / Here > Title (if line 1a above is a corporation, partnership, estate, or trust) /g.... Spouse's signature Date For Privacy Act and Paperwork Reduction Act Notice see page 2. Cat. No E Form 4506 (Rev )

22

23 Department of the Treasury - Interne,t RevenueService (99) Form 1040 U.S. Individual Income Tax Return 2011 OMB No IRS UseOnly - Do not write or staple in this space. For the year Jan. 1-Dec. 3Û 2011,or other tax year beginning, 2011, ending, 20 See Separate instructions. VOLODYMYR VENHER Make sure the SSN(s) above A and on line 6c are correct 18-12â CORNELIA ST 1 FLR APT 2 Presidential Election Campaign Check hereif you, or yaur o g" P 3 spouse if RIDGEWOOD NY filing n t'"y,",y, n $3to go to this no. Checkinga box below willnot change your tax or refund. You Spouse 1 X Single 4 Head of household (with qualifying person). (See inst.) If Filing Status 2 Married filing jointly (even if only one had income) the qualifying person is a child but not your dependent, 3 Married Check filing separately. Enter spouse's SSN above enter child's name here. $e only one box.. and full name here, > 5 Qualifying widow(er) with dependent child 6a Exemptions X Yourself. If someone can claim you as obn in $ 6 ed a dependent, do not check box 6a '~'6'b 1 if morethan four b Spouse , ,, , No. of children dependents, see, on 6c who: inst. & check here Þ C Dependents: Vf Lj (2) Dependent's (3) Dependent s (4) if child under lived with you 0 (1) First namo Last name social security number relatl nship to f f child tax 0 did not live OU creait(see mst.l with you due to divorce or separation (seeinst.)...~... Dependentson 6c not enteredabove Income adgjnumberson d Total number of exemptions claimed, , linesabove $e 1 7 Wages, salaries, tips, etc. Attach Form(s) W-2 Ba Taxable interest. Attach Schedule B4f required , Sa Attach Form(s) b Tax-exempt interest. Do not include on line 8a b W-2 here. Also 9a attach Forms Ordinary dividends. Attach Schedule B if required a W-2G and b Qualified dividends b 1099-R If tax 10 Taxable refunds, credits, or offsets of state and local income taxes was withheld. 11 Alimony received...., ,., , Business income or (loss). Attach Schedule C or C-EZ ,...,....., Capital gain or (loss). Attach Schedule D if required. If not required, check here,... Þ tj 13 If you did not 14 Other gains or (losses). Attach Form 4797, ,.., get a W-2, 15a IRA distributions a b Taxable amount b see instructions. 16a Pensions and annuities 16a b Taxable amount......,. 16b 17 Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E , 242 Enclose, but do 18 Farm income or (loss). Attach Schedule F , not attach, any 19 Unemployment compensation , 228 payment. Also, ²0a social please use security benefits 20a b Taxable amount b Form 1040-V. 21 Other income Combine amounts in the far right column for lines 7 through 21. This is your total Income t 22 45, Educatorexpenses certain businessexpensesof Ad usted reservists, performing artists, and fee-basis governmentofficials. Attach Form2108/2106-EZ 24 GrOSS 25 Health savings account deduction. Attach Form Income 26 Moving expenses. Attach Form Deductible part of self-employment tax. Attach Schedule SE Self-employed SEP, SIMPLE, and qualified plans Self-employed health insurance deduction Penalty on early withdrawal of savings a Alimonypaid b Recipient's SSN Þ 31a 32 IRA deduction ,.., Student loan interest deduction , Tuition and fees. Attach Form , Domestic production activities ded. Attach Form Add lines 23 through , Subtract line 36 from line 22. This is your adjusted gross Income Þ 37 45, 470 For JVA Disclosure, Privacy Act, and Paperwork Reduction Act Notice, TwF 1040 copyrightforms(software only) 2011 see separate instructions. â Form 1040 Tw (2011)

24 ScheduleC(Form1040)2014 TRUCKING Page 2 Name(s) VOLODYMYR VENHER Part III Cost of Goods Sold (see instructions) 33 Method(s)usedto valueclosinginventory: a X Cost b Lowerofcostormarket c Other(attachexplanation) 34 Wasthereanychangeindeterminingquantities,costs,orvaluationsbetweenopeningandclosinginventory? lf"yes,"attachexplanation "Yes," Yes PX No 35 Inventoryatbeginningofyear. Ifdifferentfromlastyear'sclosinginventory,attachexplanation Q 36 Purchaseslesscostofitemswithdrawnforpersonaluse Costoflabor. Donotincludeanyamountspaidtoyourself , Materialsandsupplies Othercosts Addlines35through , Inventoryatendofyear Costofgoodssold. Subtractline41fromline40.Entertheresulthereando ' , 485 Part IV Information on Your Vehicle. Completethispartonlyify re gcaro uckexpensesonline9 andarenotrequiredtofileform4562forthisbusiness. Seethei tions fo ne13 findoutifyoumust fileform Whendidyouplaceyourvehicleinserviceforbusinesspurposes? onth,d yea 44 Ofthetotalnumberofmilesyoudroveyourvehicled g 2014,e berofmilesyouusedyourvehiclefor: a Business b Comm seeinstru s) c Other 45 Wasyourvehicleavailableforpersonaluseduringoff-du Yes No 46 Doyou(oryourspouse)haveanotherveh ' able rpersonaluse? Yes No 47 a Doyouhaveevidencetosupportyour u Yes No "Yes," b lf"yes,"istheevidencewritten?.. ~ Yes No Part V Other Expenses w b ssexpensesnotincludedonlines8-26orline30. BANK SERVICE + RG 78 POSATAGE AND I 34 TELEPHO 851 INTERNE 439 WORKING CL S 216 LAUNRY Totalotherexpenses.Enterhereandonline27a , 965 EEA Schedule C (Form 1040) 2014

25 ~ II Notice CP11 Tax Year 2013 Notice date Social Security nu Page 4 of 4 Interest charges We are required by law to charge interest on unpaid tax from the date the tax return was due to the date the tax Is paid in full. the interest is charged as long as there is an unpaid amount due, including penalties, if applicable. (Internal Revenue Code section 6601) Period Days Interestrate interestfactor Amauntdue interestcharge 04/15/ / % $ $6.33 Total interest $6.33 We multiply your unpaid tax, penalties, and interest (the amount due) by theinterest rate factor to determine the interest due. Additional interest charges if the amount you owe is $100,000 or more, please make sure that we receive your payment within 10 work days from the date of your notice. If the amount you owe is less than $ 100,000, please make sure that we receive your payment within 21 calendar days from the date of your notice. If we don't receive full payment within these time frames, the law requires us to charge interest until you pay the full amount you owe. Additionalinformation visitwww.irs.gov/cp11 For tax forms, instructions, and publications, visit or call TAX-FORM ( ). Did you e-file your tax retum? Electronically filed returns are less likely to have math errors resulting in notices such as this one. It's free to file your taxes electronically, Go to for information and instructions. Keep this notice for your records. lf you need assistance, please don't hesitate to contact us.

26

27 ,. Departmentof the Treasury -- iüternal RevenueService (99) Form 1040 lf.s... Individual Income Tax Return 2012 OMB No IRS UseOnly -- Do not write or staple in this space. Forthe year Jan 1-Dec. 31, 2012,or other tax year beginning, 2012,ending, 20 See separate instructions. er Spouse's social security no. VOLODYMYR VENHER Make sure the SSN(s) above A and on line 6c are correct â 62ND ST APT 3H Presidential Election Campaign Check here if you, or your spouse if Ridgewood NY filing jointly, want $3to go to this fund. Checkinga box below wiiinot change your tax or refund. You Spouse 1 _ Single 4 Head of household (with qualifying person). (See inst ) If Filing Status 2 _ Married filing jointly (even if only one had income) the qualifying person is a child but not your dependent, 3 Check only _ Married filing separately. Enter spouse's SSN above enter child's name here. > one box. and full name here 5 Qualifying widow(er) with dependent child 6a Exeniptions Yourself. If someone can claim you as a dependent, do not check box 6a Bnoxeshe6bked If morethan four b SpOuSe No. of children dependents, see Vf on 6c who: idns 6 check here I Lj c Dependents: (2) Dependent's 3) Dependent's (4) if child under ~ Ii ed wîth you 0 ship to f yin for chi[d9tax did not live u cre_itfs_ee_igjild..--with credit see inst you due to divorce or separation (seeinst.) Dependents unbu not entered above 1 Income Add numberson d. Total number of exemptions claimed linesabove > 2 7 Wages, salaries, tips, etc Attach Form(s) W -2 If you did not 14 Other gains or (losses). Attach Form get a W-2, 15a IRA distributions a b Taxable amount. see instructions. 15b 16a Pensions and annuities 16a b Taxable amount.. 16b 17 Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E Educator expenses certain Ad"usted businessexpensesof â reservists, performingartists, and fee-basis governmentofficials. Attach Form2106or 2106-EZ 24 GrOSS 25 Health savings account deduction. Attach Form Penalty on early withdrawal of savings , 992 8a Taxable interest. Attach Schedule B if required a Attach Form(s) b Tax-exempt interest. Do not include on line 8a b W-2 here. Also 9a attach Forms Ordinary dividends- Attach Schedule B if required a W-2G and b Qualified dividends. 9b 1099-R if tax 10 Taxable refunds, credits, or offsets of state and local income taxes was withheld. 11 Alimony received Business income or (loss). Attach Schedule C or C-EZ Capital gain or (loss). Attach Schedule D if required. If not required, check here.. > P 13 Enclose, but do 18 Farm income or (loss)- Attach Schedule F not attach, any 19 Unemployment... payment. compensation , 036 Also' 20a Social security benefits 20a b Taxable amount 20b please use Form 1040-V 21 Other income. List type and amount Combine amounts in the far right column for lines 7 through 21. This is your total income ~ 22 51, 534 InCOme 26 Moving expenses. Attach Form Deductible part of self-employment tax. Attach Schedule SE Self-employed SEP, SIMPLE, and qualified plans Self-employed health insurance deduction a Alimonypaid b Recipient'sSSN Þ. 31a 32 IRA deduction Student loan interest deduction Tuition and fees. Attach Form Domestic production activities ded. Attach Form Add lines 23 through Subtract line 36 from line 22. This is your adjusted gross income ~ , 534 For JVA Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. Form TWF 1040 Copyright Forms(Software Only) â (2012) 2012TW

28 Form Page 2 38 Amount from line a Ius e gross income Tax and 39a Check You were born before January 2, 1948, Blind. Total boxes Credits it: Spouse was born before January 2, 1948, Blind. checked > 39a Standard b If your spouse itemizes on a separate return or you were a dual-status alien, check here k 39b Deduction Der 40 Itemized deductions (from Schedule A) or your standard deduction (see left margin) ,817 People who 41 Subtract line 40 from line ,717 ox on line 42 Exemptions. Multiply $3,800 by the number on line 6d., r600 39a or 39b or 43 Taxable income. Subtract line 42 from line 41. If line 42 is more than line 41, enter ,117 who can be claimed as a 44 Tax (see inst.). Check if any from: a Q Form(s) 8814 b Q Form 4972 c Q 962 election 44 3r59 9 d9e9pendent, see 45 Alternative minimum tax (see instructions). Attach Form instructions. 46 Add lines 44 and k 46 3,599 All others: 47 Foreign tax credit. Attach Form 1116 if required Single or Married filing 48 Credit for child 8 dependent care expenses. Attach Form rately' 49 Education credits from Form 8863, line Retirement savings credit. Attach Form Married filing jointly or 51 Child tax credit. Attach Schedule 8812, if required Qualifying widow(er), 52 Residential energy credit. Attach Form $11, Other credits from Fortn: a g 3800 b Q 8801 c Q 53 ouse 54 Add lines 47 through 53. These are your total credits old, $8, Subtract line 54 from line 46. If line 54 is more than line 46, enter > 55 3,599 Other Taxes 56 Self-ernployment tax. Attach Schedule SE Unreported social security and Medicare tax from Form: a U 4137 b p Additional tax on IRAs other qualified retirement plans, etc. Attach Form 5329 if required a Household employment taxes from Schedule H a b First-time homebuyer credit repayment. Attach Form 5405 if required b 60 Other taxes. Enter code(s) from instructions Add lines 55 through 60. This is your total tax , k Payments 62 Federal income tax withheld from Forms W-2 and , estimated tax payments & amt. applied from 2011 return 63 If you have a -64a Earned income credit (EIC) qualifying child, attach b Nontaxable combat pay election 64b Schedule ElC 65 Additional child tax credit. Attach Schedule American opportunity credit from Form 8863, line Reserved Amount paid with request for extension to file Excess social security and tier 1 RRTA tax withheld Credit for federal tax on fuels. Attach Form Credits from Form: a Q 2439 b Resrvd. c Q 8801 d Add lines 62, 63, 64a, and 65 through 71. These are your total payments I 72 3,841 Refund 73 If line 72 is more than line 61, subtract line 61 from line 72. This is the amount you overpaid a Amount of line 73 you want refunded to you. If Form 8888 is attached, check here p 74a 242 Direct deposit? + b Routing no. 0, > c Type: Checking Savings See d Account no instructions. 75 Amt. of line 73 you want applied to your 2013 estimated tax > 75 Amount 76 Amount you owe. Subtract line 72 from line 61. For details on how to pay, see instructions > 76 You OWe 77 Estimated tax penalty (see instructions) ' Third Party Do you want to allow another person to discuss this return with the IRS (see instructions)? Yes. Complete below. No Se P" 5 Designee e p Personalidentification ermsenal Sign Underpenaltiesof perjury, I declarethat I haveexaminedthis return andaccompanyingschedules and statements,andto the best of my knowledge and belief, they aretrue, correct, an complete. Declarationof preparer(other than taxpayer)is )ased on all information of which preparer hasany nowledge. Here Your signature Date Your occupation Daytime phone number Joint return? See instructions. WORKER Keep a co for yourcopy py spouse's signature.if ajoint return, both mustsign. your Date Spouse's occupation Prot t on records. PIN,enter it Print/Type preparer's name Preparer's signature Date Paid Roman Furman Preparer Firm's name k TAX TARGET GROUP LLC Use Only Firm's address k 1047 BRIGHTON BEACH AVE BROOKLYN NY JVA TWF tooo Copyright Forms(Software Only) â 2012TW Form 1040 (2012) Check if PTIN

29 4 w n 1040 Department of thetreasury â InternalRevenueService U.S. Individual Income (gg) Tax Return 0 OMB No IRSUseOniâ Donoiwriteorsia leinthiss ace. For the year Jan. 1-Dec. 31, 2013, or other tax year beginning, ending See separate instructions. Your first name M.I. Last name Suffix VOLODYMYR Suffix mber Apt. no. a e sure e (s) above NDSTREET 3H and on line 6c are correct. City, townorpostoffice,state,andzlpcode.lfyou have a foreign address,alsocompletespacesbelow(seeinstructions). Presidential Election Campaign RIDGEWOOD NY Checkhereif you,oryourspouseiffiling Foreign country name. Foreign province/state/county Foreignpostalcode Mou½an $3tugotothisfundĊuwking a boxbelowwillnotchangeourtaxor refund. ~X You X spouse Filing Status 1 Single 4 Headof household (with qualifying person). (See instructions.)if.... the qualifying person is a childbutnotyour dependent.enter this 2 X Marriedfilingjointly(evenifonlyonehadincome) child's name here. 3 Marriedfilingseparately.Enterspouse'sSSNabove andfullnamehere. Checkonlyone Firstname Last name SSN box. First name Last name 5 Qualifyingwidow(er)withdependentchild Boxeschecked Exemptions 6a X Yourself.Ifsomeonecanclaimyouasadependent,donotcheckbox6a on6aand6b 2 b X Spouse No.of children on6cwho: c Dependents: (4) if childunderage17 ~ (2) Dependent's (3) Dependent's livedwithyou 0 qualifyingfor childtaxcredit socialsecuritynumber relationshiptoyou didnotlivewith (1) Firstname Lastname (seeinstructions) youduetodivorce Ifmorethanfour D orseparation 0 (see dependents,see instructions) 0 opend t onec instructionsand 0 notenteredabove 0 checkhere > 0 Addnumberson d Totalnumberofexemptionsclaimed linesabtve 2 Income 7 Wages,salaries,tips,etc. AttachForm(s)W , a Taxableinterest. AttachScheduleBifrequired a AttachForm(s) b Tax-exemptinterest. Donotincludeonline8a b W-2here.Also 9a Ordinarydividends. AttachScheduleBifrequired a attachforms b Qualifieddividends b W-2Gand 1099-Riftax 10 Taxablerefunds,credits,oroffsetsofstateandlocalincometaxes waswithheld. 11 Alimonyreceived Businessincomeor(loss). AttachScheduleCorC-EZ Capitalgainor(loss). AttachScheduleDifrequired.Ifnotrequired,checkhere > 13 Ifyoudidnot 14 Othergainsor(losses).AttachForm e n r ions. 15a IRAdistributions a b Taxableamount b 16a Pensionsandannuities a b Taxableamount b 17 Rentalrealestate,royalties,partnerships,Scorporations,trusts,etc. AttachScheduleE ,' Farmincomeor(loss). AttachScheduleF Unemploymentcompensation ,695 20a SociaIsecuritybenefits a b Taxableamount b 0 21 Otherincome. Listtypeandamount Combinetheamountsinthefarrightcolumnforlines7through21.Thisis fourtotalincome.... > 22 23, Educatorexpenses Adjusted 24 Certainbusinessexpensesofreservists,performingartists,and Gross fee-basis government officials.attachform2106or2106-ez Income 25 Healthsavingsaccountdeduction.AttachForm Movingexpenses. AttachForm Deductiblepartofself-employmenttax.AttachScheduleSE Self-employedSEP,SIMPLE,andqualifiedplans Self-employedhealthinsurancededuction Penaltyonearlywithdrawalofsavings a Allmonypaid b Recipient'sSSN 31a 32 IRAdeduction Studentloaninterestdeduction Tuitionandfees.AttachForm Domesticproductionactivitiesdeduction.AttachForm Addlines23through31aand32through Subtractline36fromline22. Thisisyouradjustedgrossincome ~ 37 23,013 Form For Disclosure. Privacv Act. and Paperwork Reduction Act Notice. see separate instructions (2013)

30 4 Form 1040 (2013) VOLODYMYRVENHER Paged Pa e2 Tax Credits and 38 Arnount from line 37 (adjustedgrossincome) ,013 39a Check You were born beforejanuary 2, 1949, Blind. Total boxes if: ( Spouse was born before January 2, 1949, Blind. ) checked ~ 39a b If your spouse itemizes on a separate return or you were a dual-status alien, check here... > 39b D duct n for- 40 Itemized deductions (from Schedule A) or your standard deduction(seeleftmargin) ,200 Peoplewho 41 Subtract line 40 from line ,813 be on lîne 42 Exemptions. If line 38 is $150,000or less, multiply $3,900 by the numberon line6d. Otherwise,see instructions ,800 39aor 39bor 43 Taxable income. Subtract line 42 from line 41. If line 42 is more than line 41, enter ,013 whocanbe claimedas a 44 Tax (see instructions).check if anyfrom: a Form(s)B814 b Form4972 c Îe ependen 45 Alternative minimum tax (see instructions). Attach Form instructions. 46 Add lines 44 and » All others: 47 Foreign tax credit. Attach Form 1116 if required Singleor 48 Credit for child and dependent care expenses. Attach Form Marriedfiling 49 Education credits from Form 8863, line separately, se,1oo 50 Retirement savings contributions credit. Attach Form nty r 51 Child tax credit. Attach Schedule 8812, if required oualifying 52 Residential energy credits. Attach Form widow(er), SHe OthercreditsfromForm: a 3800 b 8801 c 53 us old, 54 Add lines 47 through 53. These are your total credits Subtract line 54 from line 46. If line 54 is more than line 46, enter > Other TaMS 56 Self-employment tax. Attach Schedule SE Unreported social security and Medicare tax from Form: a 4137 b Additional tax on IRAs, other qualified retirement plans, etc. Attach Form 5329ifrequired a Household employment taxes from Schedule H a b First-time homebu er credit repayment. Attach Form5405ifre uired b 60 Taxesfrom: a ~ Form8959 b Form8960 c ~ Instructions;entercode(s) Add lines 55 through 60. This is yourtotaltax PaymentS 62 Federal income tax withheld from Forms W-2 and , estimated tax payments and amount applied from 2012 return aa Earned income credit If you have a (EIC) a qualifying b Nontaxable combat pay election b cshd a ach 65 Additional child tax credit. Attach Schedule Refund 66 American opportunity credit from Form 8863,Iine Resened Amount paid with request for extension to file Excess social security and tier 1 RRTA tax withheld Credit for federal tax on fuels. Attach Form Q 71 Oreditsfrom Form: a 2439 b _ Reservedc 8885 d Add lines 62, 63, 64a, and 65 through 71. Theseareyourtotalpayments > 72 3, Ifline72ismorethan line 61, subtract line 61 from line 72. This is the amount you overpaid ,101 74a Amount of line 73 you want refunded to you. If Form 8888 is attached, check here..... > 74a 3,101 b Routing number XXXXXXXXX c Type: Checking Savings Direct deposit? See W d Account number XXXXXXXXXXXXXXXXX instructions. 75 Amount of line 73youwantappliedtoyour2014estimatedtax... > 75 Amount 76 Amountyouowe.Subtractline72fromline61. For details on how to pay,seeinstructions..... > 76 0 You Owe 77 Estimated tax penalty (see instructions) Do you want to allow another person to discuss this return with the IRS (see instructions)? X Yes.Completeb3low. No Third p Party Designee's Phone Personal identification Designee name A OKSANAINOYATOVA no.» number (PIN) i Sign Here Underpenalties of perjury, I declare that I have examined this return and accompanyingschedules and statements, and to the best of my knowledgeand belief,they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge. Joint return? See Your signature Date Your occupation Daytime phone number instructions. SUPERINTENDENT Keep a copy for Spouse'ssignature. If a joint return, both must sign. Date Spouse's occupation IftheIRSsentyouanIdentityProtection your records. PIN,enterit SELFEMPLOYED here(seeinst.) Print/Typepreparer's name Preparer's signature Date Check if PTIN Paid OKSANAINOYATOVA 3/9/2014 self-employed P Preparer Firm'sname AOKSANACOHENANDASSOCIATES Firm's EIN Use Only Firm'sadd«ss > QUEENS BOULEVARD REGO PARK NY Phone no.

31 Schedule E (Form 1040) 2013 Attachment Sequence No. 13 Page 2 Name(s) shown on return. Do not enter name and social security number if shown on other side. VOLODYMYRVENHERand MARTHAKOKHAN Caution. The IRS compares amounts reported on your tax return with amounts shown on.schedule(s) K-1. Income or Loss From Partnerships and S Corporations Note. If you report a loss from an at-risk activity for which any amount is not at risk, you must check the box in column (e) on line 28 and attach Form See instructions. 27 Are you reporting any loss not allowed in a prior year due to the at-risk, excess farm loss, or basis limitations, a prior year unallowed loss from a passive activity (if that loss was not reported on Form 8582), or unreimbursed "Yes," partnership expenses? If you answered see instructions before completing this section. Yes X No (b) Enter P for (c) Check if (d) Employer (e) Check if 28 (a) Name partnership; S foreign identification any amount is for S corporation partnership number not at risk A LUCKY VM S B C D Passive Income and Loss Nonpassive Income and Loss (f) Passiveloss allowed (g) Passive income (h) Nonpassiveloss (i) Section 179 expense (j) Nonpassiveincome (attach Form 8582 if required) from Schedule K-1 from Schedule K-1 deduction from Form 4562 from Schedule K-1 A 38,179 B C D 29 a Totals b Totals 38, Add columns (g) and (j) of line 29a Add columns (f), (h), and (i) of line 29b ( 38,179 ) 32 Total partnership and S corporation income or (loss). Combine lines 30 and 31. Enter the result here and include in the total on line 41 below ,179 Income or Loss From Estates and Trusts 33 (a) Name A B A B 34 a Totals b Totals Income or Loss From Real Estate Mortgage Investment Conduits (REMICs)-Residual Holder (b) Employer (c) Excess inclusion from I' h I '.4 (d) Taxable income (net loss) (e) Incomefrom 38 (a) Name Sc ed es identification number Q, ney2c from Schedules (see Q, line 1b Schedules Q, line 3b instructions) Your s Passive Income and Loss Nonpassive Income and Loss (b) Employer identificationnumber (c) Passivededuction or loss allowed (d) Passive income (e) Deduction or loss (f) Other incomefrom (attach Form 8582 if required) from Schedule K-1 from Schedule K-1 Schedule K-1 35 Add columns (d) and (f) of line 34a Add columns (c) and (e) of line 34b ( ) 37 Total estate and trust income or (loss). Combine lines 35 and 36. Enter the result here and include in the total on line 41 below Combine columns (d) and (e) only.. Enter the result here and include in the total on line 41 below 39 0 Summary.. 40 Net farm rental income or (loss) from Form Also, complete line 42 below Total income or (loss). Combinelines26,32,37,39,and40. EntertheresulthereandonForm1040,line17,or Form1040NR,line18.. W 41-38, Reconciliation of farming and fishing income. Enter your gross farming and fishing income reported on Form 4835, line 7; Schedule K-1 (Form 1065), box 14, code B; Schedule K-1 (Form 1120S), box 17, code V; and Schedule K-1 (Form 1041), box 14, code F (see instructions) Reconciliation for real estate professionals. If you were a real estate professional (see instructions), enter the net income or (loss) you reported anywhere on Form 1040 or Form 1040NR from all rental real estate activities in which you materially participated under the passive activity loss rules HTA Schedule E (Form 1040)2013

32 NYSCEF VOLODYMYRyENHERand DOC. NO. 43 MARTHAKOKHAN RECEIVED NYSCEF: 06/27/2018 Line 21 (Sch A - (1040)) -Unreimbursed Employee Expenses 1 UNIONDUES 1 5,897 2 Subtotalforunreimbursedemployeeexpenses , Total for unreimbursed em lo ee ex enses...,... enses ,897 Filer Spouse

33 r FILED: QUEENS COUNTY CLERK 06/27/ :14 PM INDEX NO /2016 E Department ofthetreasurȳ InternalRevenueService (99) ~ 1040 > u.s. Individual Income Tax Return 2O~4 OMBNo IRSUseOnly-Donotwriteor stapleinthisspace. FortheyearJan.1-Dec.31,2014,orothertaxyearbeginning, 2014,ending, 20 Seeseparateinstructions. Yourfirstnameandinitial. Lastname VOLODYMYR if ajointretumșpouse'sfirstnameandinitial VENRER Lastname MARTA VENHER Homeaddress(numberandstreet). Apt.no. e ND STREET Cityțownorpostoffice,state,andZIPcode.Ifyouhaveaforeignaddress,alsocompletespacesbelow(seeinstructions). Ridgewood NY Checkhereifyou,oryourspouseiffiling $2tosc tc thisfund.chcci Foreigncountryname Foreignprovince/state/county Foreignpostalcode a boxbelowwillnotchangeyourtaxor refund. You Spouse 1 Single 4 Headof household(withqualifyingperson).(seeinstructions.) If Filing thequalifyingpersonis a childbutnotyourdependent,enterthis 2 X eius Marriedfilingjointly(evenifonlyonehadincome) child'snamehere. 3 Marriedfilingseparately.Enterspouse'sSSNabove Checkonlyone box. andfullnamehere. 5 Qualifyingwidow(er)withdependentchild 6a X Yourself.lfsomeonecanclaimyouasadependent,donotcheckbox6a X sexes checked Exemptions J onsaandsb 2 b X Spouse No.of children c Dependents: (2)Dependent's Dependent's (4)C Ifchil der on Scwho ege17qualifying Ildlax credit livedwith ycu did not livewith youdueto divorce Ixl or separation Ifmorethan (seeinstructions) - dependents Dependentson 6c instructions not enteredabove - checkhere _. _... D Addnumbers on lines d Totalnumberofexemptionsclaimed above 3 7 Wages,salaries,tips,etc.AttachForm(s)W-2 ~ Income O 74, 079 8a Taxableinterest.AttachScheduleBifrequired Ba b Tax-exemptinterest.Donotinclude a ~.. 86 AttachForm(s) W-2here.Also 9a Ordinarydividends. AttachSchedu frequired a attachforms b Qualifieddividends ) 9b W-2Gand 10 Taxablerefunds,credits,oroffsets ateandloc cometaxes Riftax 11 Alimonyreceived waswithheld. 12 Businessincomeor(loss). AttachSche -EZ (9, 990) 13 Capitalgainor(loss).Att eduledifrequired.ifnotrequired,checkhere > 13 Ifyoudidnot 14 Othergainsor(losses). A orm getaw-2, seeinstructions. 15a IRAdistributions.. s. 1 b Taxableamount b annuit' 16a Pensionsandannuit. a b Taxableamount b 3, 574 Adjusted Gross Income 17 Rentalrealestate, lties,pa.ships,scorporations,trusts,etc. ships, S corporations, trusts, etc. AttachScheduleE Farmincomeor(loss.. chschedulef Unemploym ns , a Socialsec yb fit - 20a ) b Taxableamount b 21 O co bi am e far right columnfor lines 7 through 21. This is your total income , r es ' ertai ess penseeof reservists,performingartists, and fee-b ' go ment officials.attach Form 2106 or 2106-EZ Heal vingsaccountdeduction.attachform Movi xpenses. AttachForm blepartofself-employmenttax.attachschedulese employedsep,simple,andqualifiedplans Self-employedhealthinsurancededuction Penaltyonearlywithdrawalofsavings a Alimonypaid b Recipient'sSSNP 31a 32 IRAdeduction Studentloaninterestdeduction Tuitionandfees.AttachForm Domesticproductionactivitiesdeduction.AttachForm Addlines23through Subtractline36fromline22.Thisisyouradjustedgrossincome ~ 37 74, 169 ForDisclosure,PrivacyAct,andPaperworkReductionActNotice,seeseparateinstructions. EEA Form1040(2014)

34 r FILED: QUEENS COUNTY CLERK 06/27/ :14 PM INDEX NO /2016 Form 4562 Depreciation and Amortization OMB No (Including Information on Listed Property) 2014 Þ Attach to your tax return' Department ofthetreasury Attachment InternalRevenueService(99) + Information about Form 4562 and its separate instructions is at Sequence No. 179 Name(s)shownonreturn Businessoractivitytowhichthisformrelates VOLODYMYR & MARTA VENHER SCHEDULE C - 1 Partl Election To Expense Certain Property Under Section 179 Note: If you have any listed property, complete Part V before you complete Part l. 1 Maximum amount (see instructions) , Total cost of section 179 property placed in service (see instructions) , Threshold cost of section 179 property before reduction in limitation (see instructions) , / 000, / Reduction in limitation. Subtract line 3 from line 2. If zero or less, enter Dollar limitation for tax year. Subtract line 4 from line 1. If zero or less, enter -0-. If married filing separately, see instructions , (a) Descriptionofproperty (b) Cost(businessuseonly) (c) Electedcost LAPTOP Listed property. Enter the amount from line Total elected cost of section 179 property. Add amounts in column (c), lines 6 and Tentative deduction. Enter the smaller of line 5 or line Carryover of disallowed deduction from line 13 of your 2013 Form Business income limitation. Enter the smaller of business income (not less than zero) or li (see instructions) 11 64, Section 179 expense deduction. Add lines 9 and 10, but do not enter more than li ~ Carryover of disallowed deduction to Add lines 9 and 10, less line 12 > 13 Note: Do not use Part il or Part ill below for listed property. Instead, use Part V. Part II Special Depreciation Allowance and Other Dep ation not i ude listed property.) (See instructions.) 14 Special depreciation allowance for qualified property (other than listed e n service during the tax year (see instructions) Property subject to section 168(f)(1) election Other depreciation (including ACRS) Part IH MACRS Depreciation (Do not incl listed pro. instructions.) 17 MACRS deductions for assets placed in service in t ears beginn before lf you are electing to group any assets placed in servi 'ng t year into one or more general asset accounts, check here S Section B - Assets Plac rvice During 2014 Tax Year Using the General Depreciation System (a) Classificationofproperty (b) Mont ar (c) Basisfordepreciation place ~ ' in (business/investment use (d) Recovery. (e) Convention ce period -seeinstructions) (f) Method (g) Depreciationdeduction 19a 3-year property b 5-year property Statement #1 9,623 c d e f 7-year property 10-year property 15-year property 20-year property g 25-year prope 25 yrs. S/L h Residential rental 27.5 yrs. MM S/L property 27.5 yrs. MM S/L i Nonre ntial real 39 yrs. MM S/L prope MM S/L Sectio -Assets Placed in Service During 2014 Tax Year Using the Afternative Depreciation System 20a Class life S/L b 12-year 12 yrs. S/L c 40-year 40 yrs. MM S/L Part IV) Summary (Seeinstructions.) 21 Listed property. Enter amount from line Total. Add amounts from line 12, lines 14 through 17, lines 19 and 20 in column (g), and line 21. Enter here and on the appropriate lines of your return. Partnerships and S corporations - see instructions , For assets shown above and placed in service during the current year, enter the portion of the basis attributable to section 263A costs For Paperwork Reduction Act Notice, see separate instructions. Form 4562 (2014) EEA n A

35 E d8 ~ g ~ Department ofthetreasurȳintemalrevenueservice (99) e 1040 u.s. Individual Income Tax Return <0 I 5 OMBNo IRSUreOnly-Donotwriteorstapleinthisspace. FortheyearJan.1-Dec.31,2015,orothertaxyearbeginning, 2015,ending, 20 See Separate instructions. Yourfirstnameandinitial Lastname Y VOLODYMYR NHER s ND STREET andonline6carecorrect. Cityțownorpostofficeștate,andZIPcode.Ifyouhaveaforeignaddress,alsocompletespacesbelow(seeinstructions). PresidentialElectionCampaign Ridgewood NY Checkhereifyou,oryourspouseiffiling jointly, want$3togoto thisfund. Foreigncountryname Foreignprovince/state/county Foreignpostalcode a boxbelow I notchangeyourtaxor Checking refund You Spouse Filing Status 1 Single 4 Headofhousehold(withqualifyingperson).(Seeinstructions.) If -... thequalifyingpersonisa childbutnotyourdependent, enterthis 2 X Marriedfilingjointly(evenifonlyonehadincome) child'snamehere. 3 Marriedfilingseparately. Enterspouse'sSSNabove Checkonlyone box. andfullnamehere. 5 Qualifyingwidow(er)withdependentchild 6a X Yourself.Ifsomeonecanclaimyouasadependent,donotcheckbox6a t Boxeschecked Exemptions X f on saandsb 2 b Spouse No.of children c Dependents: (2)Dependent's ' Dependent's (4)ChkIfuahi childunder on 6cwho: age17quarfiytng (1)Firstname Lastname socialsecuritynumber r nshipto you forchildtaxcredit livedwithyou seeinstructions a did notlivewith youdueto divorce RIANNA VENHER er maduer tior If rath four IGOR VENHER Par (seeinstructions) dependents, see Dependentson 6c and notenteredabove checkhere PO O Addnumbers t' I' on lines d Totalnumberofexemptionsclaimed above Wages,salaries,tips,etc.AttachForm(s)W-2 ~ ~ ~ Income O a Taxableinterest.AttachScheduleBifrequired a b Tax-exemptinterest.Donotinclude a ~.. 8b AttachForm(s) W-2here.Also 9a Ordinarydividends. AttachSchedul frequired a attachforms b Qualifieddividends b and, 10 Taxablerefunds,credits,oroffsets ateandlo cometaxes Riftax 11 Alimonyreceived waswithheld. 12 Businessincomeor(loss). AttachSche C-EZ ( 2, ) 13 Capitalgainor(loss).A eduledifrequired.ifnotrequired,checkhere S' 13 Ifyoudidnot 14 Othergainsor(losses). A orm getaw-2, seeinstructions. 15a IRAdistributions b Taxableamount b Pensionsandannuit' annuit' 16a Pensions and. a b Taxableamount b Adjusted Gross Income 22 bi am e far rightcolumnfor lines7 through21. This is yourtotal income Þ 22 87, 471 blepartofself-employmenttax.attachschedulese employedsep,simple,andqualifiedplans Aptno. 17 Rentalrealestate, lties,pa ships,scorporations,trusts,etc. AttachScheduleE Farmincomeor(loss.. chschedulef Unemploy ns , s Socialse b fit - 20a b Taxableamount b 21 O r co or es ' ertai ess ensesof reservists,performingartists,and fee-b ' g ment officials.attach Form2106or 2106-EZ Heal vingsaccountdeduction.attachform Movi xpenses. AttachForm Self-employedhealthinsurancededuction Penaltyonearlywithdrawalofsavings a Alimonypaid b Recipient'sSSNA 31a 32 IRAdeduction StudentIoaninterestdeduction Tuitionandfees.AttachForm Domesticproductionactivitiesdeduction.AttachForm Addlines23through Subtractline36fromline22.Thisisyouradjustedgross income Þ 37 87, 471 For Disclosure,PrivacyAct,andPaperworkReductionActNotice,seeseparateinstructions. EEA Form1040(2015)

36 ' Form 1040 (2015)VOLODYMYR VENHER & MARTA KOKHAN Tax and S 38 Amount from line 37 (adjusted gross income) a Check You were bom before January 2, 1951, Blind Total boxes if: ( Spouse was bom before January 2, 1951, Blind. } checked 99 39a P b If your spouseitemizeson a separatereturnor youwere a dual-statusalien, checkhere.. - b 39b s 40 Itemized deductions (from Schedule nucton A) or your standard deduction (see left margin) ,600 for - 41 Subtract line 40 from line ,871 People who 42 Exemptions. Ifline38is$154,950orless,multiply84000bythenumberonline6d.Otherwise, seeinstructions ,000 checkany boxon line 43 Taxable income. Subtract line 42 from line 41. If line 42 is more than line 41, enter ,871 o be ' 3n 44 Tax (see instructions). Check if any from: a Form(s)8814 b Form49720 Q 44 7,909 claimedas a 45 Afternative minimum tax (see instructions). Attach Form dependent, see 46 Excess advance premium tax credit repayment. Attach Form instructions. 47 Add lines 44, 45, and k 47 7,909 All others: 48 Foreign tax credit. Attach Form 1116 if required Singleor Marriedfiling 49 Creditfor childand dependentcareexpenses.attach Form P30rately, 50 Education credits from Form $6, ,r line Retirement savings contributions credit. Attach Form Marriedfiling jointly or 52 Child tax credit. Attach Schedule 8812, if required Qualifying widow(er), 53 Residential energy credit. Attach Form , Othercreditsfrom Form:a 3800 b 8801 c 54 Headof household, 55 Add lines 48 through 54. These are your total credits ,000 $9, Subtract line 55 from line 47. If line 55 is more than line 47, enter Þ 56 6, Self-employment tax. Attach Schedule SE -...., Other 58 Unreported social security and Medicare tax from Form: TaxeS 59 Additional tax on IRAs, other qualified retirement plans, etc ch 5329 i quired a Household employment taxes from Schedule H - -. ~ s ' b First-time homebuyer credit repayment. Attach Form 5 5 i b 61 Health care: individual responsibility (see instructi ar age X Taxes from: a Q Form 8959 b Form 8 c I ations r code(s) Excess social securi RR tax withheld - -. " ThirdPa o you wan allow another person to discuss this return with the IRS (see instructions)? Yes. Complete below. No npho Phoebe Personaidentification Designee 9 no number(pi Un esofperjury, IdeclarethatI haveexaminedthisreturnandaccompanying schedulesandstatements, andtothebestofmyknowledgeandbelief, Sign theyaretrue,correct,andcomplete.declarationofpreparer(otherthantaxpayer) isbasedonallinformationofwhichpreparerhasanyknowledge. Yoursignature Date Youroccupation Daytimephonenumber Here driver â Joint return? See instructions. Spouse'signature. If ajointreturn,bothmustsign. Date Spouse'soccupation IdentityProtectionPIN(seeinst.) Keepa copyfor yourrecords anemploed Preparer'signature - Date Check if PTIN Olga Zelenkova self-employed P PWd Printrrypepreparer'sname Olga Zelenkova Preparer Firm'sname + Tax integrity LLC Firm'sEIN > UseOnly Firm'saddress Bath ave â â Brooklyn, NY Phoneno EEA orm 1040 (2015 g 63 Add lines 56 through 62. This is your t Þ Payments 64 Federal income tax withheld from F s W-2 and estimatedtax paymentsand amo appliedfrom 2 return a Earned income credit n (EIC) a child,attach b Nantaxablecombatpay election -. - ScheduleEIC. 67 Additional child tax credit. Attach Schedu American opportunity c Form 8863, line Net premium tax credit. A rm ' 70 Amount paid with req r e file ~: Credit for federal t fuels. h Form Creditsfrom Form: a b I Reservedc 8885 d _ Add lines 64, an brough 73. These are your total payments h 74 8,449 Refund 75 If line 74 is re n 63, subtract line 63 from line 74. This is the amount you overpaid 75 1,540 76a AlÊn of I you. nt refunded to you. If Form 8888 is attached, check here - Ib 76a Directdeposit?» b utin b »c Type: X Checking Savings see.» d tn instructions. ou 7 u want applied to your 2016estimated tax... Sb 77 Amount 78 Amo t we.. Subtract line 74 from line 63. For details on how to pay, see instructions Þ 78 YouOwe 79 Esti d tax penalty (see instructions)

37 Department ofthetreasury-intemalrevenueservice â 4 (99) 20~ 0 U.S. Individual Income Tax Return 6 OMB No IRSUseOnly-Do â notwriteorstapleinthisspace. FortheyearJan.1-Dec.31,2016,orothertaxyearbeginning, 2016,ending, 20 See separate instructions. - - Your first name and initial Last name VOLODYMYR If a joint return, spouse's first name and initial VENHER Last name VENHER KOKHAN Home address (number and street). If you have a P.O. box, see instructions. Apt. no th AVE 3 City,townor postoffice,state,andzipcode.ifyouhavea foreignaddress,alsocompletespacesbelow(seeinstructions)- Presiden ection Campaign Rid ewood NY ourspouseiffiling 'efund. Foreign country name Foreign province/state/county Foreignpostalcode Checking aboxbelowwillno ur o Spouse (w' 1 O Single 4 0 Head of household(w ifyin on). (Seeinstructions.)If Filing Status 2 8 Married filing jointly (even if only one had income) the qualifying pars hild b your dependent,enterthis Check only one 3 [3 Married filing separately. Enter spouse's SSN above child's namehere. 1. box. and full name here. W 5 Qualifying wi wit ent child 6a Exemptions IK Yourself. If someone can claim you as a dependent, do not check bo s ch ed on 6a and 6b b g Spouse No. of children c Dependents: (2)Dependent's (3)Dependent's if childunderag on 6 who: forchildiax ~ lived with you 2 struction did not live with you due to divorce or separation If more than fo (seeinstructions) dependents, Dependentson 6c instructions an not entered above check here tu Q Add numbers on d Total number of exemptions claimed lines above p 4 Income 7 Wages, salaries, tips, etc. Attach Form(s) W ,401. 8a Taxable interest. Attach Schedule B if required a b Tax-exempt interest. Do not include on line 8.. 8b / Attach Form(s) 9a Ordinary dividends. Attach Schedule B ifr a W-2 here. Also attach Forms b Qualified dividends b W-2G and 10 Taxable refunds, credits, or offsets of d local inco es R if tax 11 Alimony received was withheld' If you did not get a W-2, see instructions. 12 Business income or (loss). Attac C , Capital gain or (loss). Attach Sc ot required, check here > Q Other gains or (losses). Att or a IRA distributions. b Taxable amount... 15b 16a Pensions and annuities b Taxable amount... 16b 17 Rental real estate, r hi orporations, trusts, etc. Attach Schedule E Farm income or s).. hed Unemployment sati , a Social security ben i b Taxable amount... 20b 21 Other income. List type unt Combi e amounts in the f t column for lines 7 through 21. This is your total income W , Educ ses Adjusted ' 24 c busi n servists, performing artists, and Gross s govem is. Attach Form 2106 or 2106-EZ 24 MCOme 25 ealth savi c t deduction. Attach Form oving ex s. Attach Form ctible p self-employment tax. Attach Schedule SE SEP, SIMPLE, and qualified plans Self- oyed health insurance deduction Penalty on early withdrawal of savings a Alimony paid b Recipient's SSN Þ 31a 32 IRA deduction Student loan interest deduction Tuition and fees. Attach Form Domestic production activities deduction. Attach Form Add lines 23 through Subtract line 36 from line 22. This is your adjusted gross income , For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate Instructions. BAA Rav of/2sny PRo Form 1040 (2016)

38 4 Forrn1040(2016) Page 2 Tax CreditS and 38 Amount from line 37 (adjusted gross income) , a Check You were bom before January 2, 1952, Blind. Total boxes if: O Spouse was bom before January 2, 1952, Q Blind. checked A 39a b If your spouse itemizes on a separate return or you were a dual-status alien, check here a 39b Standard 40 Itemized deductions (from Schedule A) or your standard deduction (see left margin) , ction 41 Subtract line 40 from line , People who 42 Exemptions. If line38 is$155,650or less,multiply$4,050by the numberon line6d. Otherwise,seeinstructions 42 16, 200. hexokni ne 43 Taxable income. Subtract line 42 from line 41. If line 42 is more than line 41, enter , O a or 39b or 44 Tax (see instructions). Check if any from: a Q Form(s) 8814 b Form 4972 c U who can be claimed as a 45 Alternative minimum tax (see instructions). Attach Form dependent see 46 Excess advance premium tax credit repayment. Attach Form instructions. 47 Add lines 44, 45, and Q All others: 48 Foreign tax credit. Attach Form 1116 ifrequired Single or Married filing 49 Credit for child and dependent care expenses. Attach Form ÊG30 50 Education credits from Form 8863, line Married filing 51 Retirement savings contributions credit. Attach Form jointly Ouai,fy(n or 52 Child tax credit. Attach Schedule 8812, if required Residential $12,600 energy credits. Attach Form Head of 54 Othercredits from Forrn: a O 3800 b O 8801 c 54 sehold, 55 Add lines 48 through 54. These are your total credits $9,300, 56 Subtract line 55 from line 47. If line 55 is more than line 47, enter Taxes gr 57 Self-employment tax. Attach Schedule SE Unreported social security and Medicare tax from Form: a O Additional tax on IRAs, other qualified retirement plans, etc. Attach F 329 if req a Household employment taxes from Schedule H s b First-time homebuyer credit repayment. Attach Form 5405 ifrequired... 60b 61 Health care: individual responsibility (see instructions) Fu ear coverage Taxes from: a P Form 8959 b O Form 8960 c ructions; enter code(s) Add lines 56 throu h 62. This is our total tax Payments 64 Federal income tax withheld from Forms W-2 an 64 3, fff estimated tax payments and amount applied ro 015 re If you have a 66a Earned income credit (EIC) , 816. qualifying hi attach b Nontaxable combat pay election 66b Schedule EIC. 67 Additional child tax credit. Attach Sched. 67 1, American opportunity credit from Fo Net premium tax credit. Attach F Amount paid with request for e lon o file Excess social security and tie TA thheld Credit for federal tax on fu c CreditsfromForm:a Q d Add lines 64, 65, 66a, thro e are your total payments..... ~ 74 7, 652. Refund 75 If line 74 is more than line trac 63 from line 74. This is the amount you overpaid 75 7, a Amount of line 75 you want o you. If Form 8888 is attached, check here. > j3 76a 7, Direct deposit? Þ b Routing num I * * * I * W c Type: [g Checking Savings See i ~/i" W d Account nu * * * 8 5 Ï 1 4,j instructions. 77 Amount o ' e 75 t a to your 2017 estimated tax W 77 Amount 78 Am owe. S e 74 from line 63. For details on how to pay, see instructions I 78 You Owe 79 Es ed tax pen (se structions) ii': g///ffpfffffff f$/f Third Do yo nt to allow er person to discuss this return with the irs (see instructions)? Party g Yes. Complete below. O No Design Phone Personal identification Signee name W sarkova no.» ( ) number * * * * * (PIN) Underpenaltiesofp at I haveexaminedthisreturnandaccompanying schedulesandstatements, andto thebestofmyknowledgeandbelief,theyaretrue,correct,and accuratelylistallamounts sourcesof incomeireceivedduringthetaxyear.declarationofpreparer (otherthantaxpayer) isbasedonallinformationofwhichpreparerhasanyknowledge. Your signature Date Your occupation Daytime phone number Jointreturn?See TRUCK DRIVER Keepa copyfor Spouse's signature. If a joint return, both must sign. Date Spouse's occupation IftheIRSsentyouanidentityProtection yourrecords. HOUSEWIFE s inst.) Print/Type preparer's name Preparer's signature Date PTIN Paid Check K if Oksana Tsarkova Oksana Tsarkova 03/10/2017 self-employed Pr * * * * * er Firm's name w Solutions USS Way LLC Firm'sEIN> **-*** Only Firm'saddress > 6614 ROCKLEDGE DR BRECKSVILLE OH Phone no. (4 4 0 ) REV01/25/1?PRQ Form (2016)