Subpoena {LIBC-480}

WRUNHUV¶ &RPSHQVDWLRQ Office of Adjudication ____ ____________________________________ FIELD OFFICE STREET ADDRESS ____ ____________________________________ FIELD OFFICE CITY, STATE, ZIP &20021:($/7+ 2) 3(116</9$1,$ '(3$570(17 2) /$%25 ,1'8675< 72 1$0( $''5(66 $''5(66 $''5(66 $''5(66 $''5(66 SUBPOENA Employee Social Security Number: XXX-XX- ___ ___ ___ ___ %85($8 &/$,0 180%(5 DATE OF INJURY &/$,0$17 NAME VS DEFENDANT NAME  YOU ARE HEREBY ORDERED, SXUVXDQW WR WKH SURYLVLRQV RI WKH :RUNHUV¶ &RPSHQVDWLRQ $FW WR FRPH WR D DW VSHFLI\ IXOO DGGUHVV RQ GDWH XQWLO H[FXVHG (2) Bring to the hearing deposition the following documents regarding the above-captioned claimant: LQ WKH &RXQW\ RI KHDULQJ OR GHSRVLWLRQ to testify in the above case, and to remain (3) THIS IS A RECORDS CUSTODIAN DEPOSITION PURSUANT TO 34 PA. CODE SECTION 131.68. You may comply with this subpoena by mailing or delivering legible copies of the documents requested by this subpoena to the party making the request, at the following address: The records must be received by the requesting party on or before Affidavit of Records Custodian attached to this subpoena. . The records must be accompanied by the executed Deposition (4) This you are to obey, without excuse, under penalty of contempt of court for noncompliance. :,71(66 0< +$1' $1' 6($/ 2) 7+( '(3$570(17 2) /$%25 ,1'8675< 6($/ DATE: :25.(56¶ &203(16$7,21 -8'*(¶6 1$0( DO NOT MAIL THE REQUESTED RECORDS TO THE BUREAU OF WORKERS' COMPENSATION OR TO THE WORKERS' COMPENSATION JUDGE'S OFFICE ,QTXLULHV FRQFHUQLQJ WKLV VXESRHQD VKRXOG EH DGGUHVVHG WR $WWRUQH\ 1DPH RU /DZ )LUP $WWRUQH\ $GGUHVV $WWRUQH\ 7HOHSKRQH 1XPEHU /,%& 5(9 Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program American LegalNet, Inc. www.FormsWorkFlow.com