COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.DIRECTDEPOSIT ACTBANKCHANGEBetter Workers' CompensationBuilt with you in mind.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)INSTRUCTIONS:Pleaseprintortype.. Pleaseattachavoidedcheckordepositslipforthenewaccount.. Allinformationmustbecompletedinorderforthisformtobeprocessed. ReturnthisformtoBWCBenefitsPayable,,P.O.Box15429,Columbus,OH 43215-0429*NEW BANKINFORMATION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .NOTE: Completethissectionifyouarechangingdirectdepositinformation. Pleasekeepoldbankaccountopenuntilpaymentsarereceived innewbankaccount. BanknameTHE PEOPLE OF THE STATE OF NEW YORK TOAccountholderBankaccountnumberBanktransitroutingnumberSavings CheckoneCheckingGREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,INJUREDWORKERINFORMATIONlocated at County ofCurrenttelephonenumberInjuredworkernameo'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)(Claimnumber(s)SocialSecuritynumberYour 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.DateInjuredworkersignature, one of the Justices of theCourt in Witness, Honorableday of, 20 County,(Attorney must sign above and type name below)Attach voided check or deposit slip hereAttorney(s) forOffice and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:BWC-0045(Rev.5/9/2003) A-35American LegalNet, Inc. www.USCourtForms.com
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