COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.CENTRE COUNTY DRS CHANGE OF EMPLOYER FORM Client for whom employer change applies(please check one):JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)PlaintiffYour Name and Social Security Number (please print)Defendant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Your Name and Social Security Number (please print)OLD EMPLOYER:THE PEOPLE OF THE STATE OF NEW YORK TODate Employment EndedName of EmployerGREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the HonorableStreet Address,located at County 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 roomCity, State, ZIPAre you collecting unemployment compensation? If so, please indicate date compensation began.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.NEW EMPLOYER:, one of the Justices of theEffective Date of New EmploymentCourt in Witness, Honorableday of, 20 County,Do you have medical insurance available at new employment? If so, please indicatename of provider and parties covered.(Attorney must sign above and type name below)Rate of PayAttorney(s) forName of New EmployerName of ProviderStreet AddressDate Coverage BeganOffice and P.O. AddressCity, State ZIPPersons Covered by Medical InsuranceTelephone No.: Facsimile No.: E-Mail Address:SignatureMobile Tel. No.:DateAmerican LegalNet, Inc. www.USCourtForms.com
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