COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Court of Claims of Ohio Capitol Square Office Building 65 East State Street, Suite 1100 Columbus, Ohio 43215 (614) 466-7190Calendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)(1)Case Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .plaintiff's nameageinsert assigned case number(2)street addressTHE PEOPLE OF THE STATE OF NEW YORK TO(3)(AMENDED) citystatezip(4)FORM COMPLAINT telephone (business)GREETINGS:area codeWE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable(5)telephone (home),area codelocated 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 roomNOTE: if you move or change telephone numbers youmust give the Court written notice of the new address or telephonenumber (6) defendant state department, board, commission, etc. (7)street address (8)cityYour 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., one of the Justices of thestatezipCourt in Witness, Honorableday of, 20 County,The defendant listed in 6 above through its agent(s) (9)(Attorney must sign above and type name below)fill in name(s) and title(s) of the agents if known, if unknown state unknowndid on or about (10)(11)M. fill in datestate approximate hourAttorney(s) for(12) Describe in ordinary language the basis of the claim (see instructions)Office and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.CC-3 P1 REV 6/01Calendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)COURT OF CLAIMS OF OHIO(12) Continued. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .THE PEOPLE OF THE STATE OF NEW YORK TOGREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,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 roomYour 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.causing plaintiff the following injury, damage or loss (13), one of the Justices of theCourt in Witness, Honorableday of, 20 County,list each item separately(Attorney must sign above and type name below)Attorney(s) forfor a total claim of (14)Office and P.O. AddressThe witnesses, if any, to the injury, damage or loss are (15)Fill in name and addressTelephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.CC-3 P2 REV 6/91Calendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)COURT OF CLAIMS OF OHIO(16) I (circle the appropriate word or phrase)/have/do not have/ insurance coverage for the injury, damage or loss with the (17)fill in company name and address and policy numberThe policy has a (18) $deductible provision. (19) I (circle the appropriate word. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .or phrase)/have/have not/ received insurance payment(s) in the amount of (20)$as a result of the incident described above. (see instructions).I ask the Court to grant a judgment in the amount stated in blank (14).THE PEOPLE OF THE STATE OF NEW YORK TOIf the amount exceeds $2,500.00 the Court may required that civil rules complaint be filed.Under the penalties of perjury and falsification, I state that I have read or had read to me the above complaint and that it is true. Further,I expressly waive, on behalf of myself and of any person who shall have any interest in this claim, all provisions of law forbidding any physician or other person who has heretofore attended or examined me, or who may hereafter attend or examine me from disclosing any knowledge or information which they thereby acquired.GREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,(21) signature of plaintiff (see instructions)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 roomBE SURE TO INCLUDE FILING FEE AND TO GIVE THE COURT WRITTEN NOTICE OF ADDRESS CHANGES (see Instructions)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.NOTE: Plaintiff need not have an attorney. If plaintiff files the complaint without an attorney, plaintiff completes Blank (21). If plaintiff files through an attorney, plaintiff signs Blank (21) and the attorney signs Blank(22) and completes Blanks (23) through (25)., one of the Justices of theCourt in Witness, Honorableday of, 20 County,Pursuant to Civil Rule 11, I state I have read the above complaint; that to the best of my knowledge, information, and belief there is good ground to support it; and that it is not interposed for delay.(Attorney must sign above and type name below)(22)signature of plaintiff's attorney(23)Attorney(s) forstreet address(24) cityzipstateOffice and P.O. Address(25) telephonearea codeTelephone No.: Facsimile No.: E-Mail Address:CC-3 P3 REV 6/91Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.com
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