Persons With Knowledge List {403}

Form 403 3/1/12 StateofUtah­LaborCommission AdjudicationDivision 160East300South,3rdFloor,P.O.Box146615 SaltLakeCity,Utah841146615 (801)5306800 casefiling@utah.gov Note:PLEASETYPEORPRINTINBLACKINK CaseName:_____________________________________________vs. DateofInjury/PeriodofExposure: _____________________ PERSONSWITHKNOWLEDGELIST Thefollowingperson(s)mayhaveknowledgeoftheeventsand/orcircumstancesrelatingto thereasonstoterminateorreducecompensation.Theperson(s)listedmayhaveknowledge thateithertendstoproveordisprovethereasonsfortermination/reductionof compensationasallegedintheApplicationforHearingforTerminationorReductionof Compensation.Attachadditionalpagesasneeded. NAME: FullName Address City State ZipCode STATEMENTOFKNOWLEDGE WitnessatHearing?_______Yes_______No TelephoneNumber WitnessatHearing?_______Yes_______No FullName Address City State ZipCode TelephoneNumber FullName Address City TelephoneNumber American LegalNet, Inc. www.FormsWorkFlow.com WitnessatHearing?_______Yes_______No State ZipCode Form 403 3/1/12 NOTICE TO THE RESPONDENT (EMPLOYEE): 15 days prior to the scheduled hearing, you are required to mail to or otherwise serve on the petitioner a list of all witnesses, other than yourself, that you will produce at the hearing. Failure to disclose a witness on the witness list may prevent that witness from being allowed to testify at the hearing. You are also required to mail to or otherwise serve on the petitioner a copy of all exhibits not otherwise in the possession of the petitioner that you intend to submit as evidence at the hearing. Failure to provide copies of exhibits prior to the hearing may prevent those documents from being submitted and considered at the hearing. American LegalNet, Inc. www.FormsWorkFlow.com