COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.Court of Claims of OhioJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)Capitol Square Office Building 65 East State Street, Suite 1100 Columbus, Ohio 43215Web siteTelephonewww.cco.state.oh.us(614) 466-7190(800) 824-8263. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .THE PEOPLE OF THE STATE OF NEW YORK TOPoverty Statement (Affidavit)GREETINGS:PlaintiffWE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorablev.Case No.,located at County ofo'clock in the day ofnoon, and at any recessed in room, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of theDefendantYour 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.I,, state under the penalties of perjury andfalsification that I am indigent and that payment of the $25.00 filing fee would create a financial hardship for me., one of the Justices of theCourt in Witness, Honorableday of, 20 County,(Attorney must sign above and type name below)Plaintiff's signature*Attorney(s) forDate*Under R.C. 2921.11,R. .C. 2929.11 and 2929.18 perjury is a felony of the third degree and punishable by imprisonment of one to five years and a fine up to $10,000.00 Under R.C. 2921.13 and R.C. 2929.21 falsification is a misdemeanor of the first degree and punishable by imprisonment of six months and a fine not more than $1,000.00.Office and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.com
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