The document is a completed IRS Form 4506‑T (September 2018 version) submitted by taxpayer Valerie Vess Jimenez on February 1, 2021. It requests a Record of Account transcript for Form 1040 covering the tax years ending December 31, 2017, 2018, and 2019. The transcript is to be mailed to the U.S. Small Business Administration Office of Disaster Assistance. The form includes the taxpayer’s current address (2762 Scott Blvd., Santa Clara, CA 95050), Social Security Number (617‑29‑5443), and a signed attestation of authority. All required lines are completed, and the request is signed and dated, complying with IRS instructions for third‑party disclosure.
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Record of Account Transcript Request for 2017‑2019
Specifies the request for a combined Return and Account transcript (Record of Account) for Form 1040 for the three most recent tax years.
Third‑Party Delivery to SBA Disaster Assistance
Designates the U.S. Small Business Administration Office of Disaster Assistance as the third‑party recipient of the transcript.
Taxpayer Identification and Contact Information
Provides Valerie Vess Jimenez’s name, SSN, and current mailing address, establishing identity for the request.
Authorization and Signature Attestation
Includes the taxpayer’s signature, date, and declaration of authority to request the transcript, satisfying IRS privacy safeguards.