COURT COUNTY OFSTATE OF NEW YORK WORKERS' COMPENSATION BOARD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.WORLD TRADE CENTER VOLUNTEER'S CLAIM FOR COMPENSATIONANSWER ALL QUESTIONS FULLY -PRINT OR TYPE CLEARLYCalendar No.IMPORTANTE: El Numero de su Seguro Social Debe Ser Indicado: IMPORTANT: Your Social Security Number Must Be Entered:Plaintiff(s) -against-Defendant(s)1. Name........................................................................................................................... 2. Mailing Address........................................................................................................................ 3. SexMiddle NameLast Name JUDICIAL SUBPOENAA. InjuredpersonMaleFemaleDate of Birth..................................Telephone No. ()............................4. Do you speak English?YesNoIf no, what language do you speak?.................................................. First Name1. Did a volunteer agency or a rescue entity direct you to go to Ground Zero or its vicinity or to the Staten IslandLandfill ?YesNo If Yes, name of agency or entity................................................................................ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B. Place/Time2. What date(s) were you volunteering at or near Ground Zero or the Staten Island Landfill: .................................................................................................................................................................. 3. Date of injury/illness.................................................... at .........................o'clock,AMPMTHE PEOPLE OF THE STATE OF NEW YORK TO1. How did injury/illness occur?.........................................................................................................................C. The Injury.............................................................................................................................................................................................................................................................. 2. Who was directing your activities at the time the injury/illness occurred? ........................................................... 3. What organization, if any, did the person directing your activities at the time of the injury/illness represent? ........GREETINGS:...............................................................................................................................WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable1. State fully the nature of your injury/illness, including all parts of body injured......................................................,located at County ofD. Nature and Extent ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in room.............................................................................................................................................................................................................................................................. 2. Did you stop regular work because of this injury/illness?YesNo If Yes, date stopped...........................Injury/Illness3. If you stopped regular work, have you returned to work?YesNo If Yes, date returned..........................4. Name of Regular Employer....................................................................................................................... 5. Address of Regular Employer.......................................................................................................................Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.1. Have you received any benefits from the Crime Victim's Fund or any other agency due to your injury?YesNoIf Yes, amount: $............................. received from.........................................................2. Did you receive or are you now receiving medical care?NoYes, one of the Justices of the3. Are you now in need of medical care?NoYesCourt in Witness, Honorableday of, 20 County,4. Name of attending doctor.........................................................................................................................E. Benefits/MedicalDoctor's address........................................................................................................................ 5. If you were in a hospital, give the dates hospitalized.........................................................................................Care(Attorney must sign above and type name below)Attorney(s) forName of hospital....................................................................................................................... Hospital's Address........................................................................................................................ 6. Did you incur any out-of-pocket expenses for medical care to treat the injury/illness sustained?NoYesIf Yes, what is the total amount of out-of-pocket expenses incurred? .................................................................I hereby present my claim for compensation for injury/illness resulting from volunteer work at Ground Zero, and in support of it I make the foregoing statement of facts.Office and P.O. AddressANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD PRESENTS, CAUSES TO BE PRESENTED, OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED, ANY INFORMATION CONTAINING ANY FALSE MATERIAL STATEMENT OR CONCEALS ANY MATERIAL FACT SHALL BE GUILTY OF A CRIME AND SUBJECT TO SUBSTANTIAL FINES AND IMPRISONMENT.Telephone No.: Facsimile No.: E-Mail Address:Signed by......................................................................................................... Dated........................................................ (Claimant)Send completed form to: NYS Workers' Compensation Board, PO Box 5205, Binghamton, NY 13902-5205.Mobile Tel. No.:WTCVol-3 (2-04)SEE OTHER SIDE FOR IMPORTANT INFORMATION -VEASE AL DORSO PARA INFORMACION DE IMPORTANCI
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