Index No.:::::: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Calendar No.DEPARTMENT OF HEALTH AND HUMAN SERVICESFORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICESOMB NO. 0938-0355JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)CALENDAR WORKSHEET -PRESCRIBEDFreq/wksFreq/wksFreq/wksFreq/wksSNHHAPTOTSTMSWSOC DATE:According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0355. The time required to complete this information collection is estimated to average 1 hour 10 minutes per response, including the time to review instructions, searching existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.THE PEOPLE OF THE STATE OF NEW YORK TOGREETINGS:Fill in days of week; begin with SOC date/dayWE 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 of, at or adjourned date, to testify and give evidence as a witness in this action on the part of the, 20, on thenoon, and at any recessed in roomo'clock in the day ofWEEK 1Your 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.WEEK 2WEEK 3, one of the Justices of the, 20 County,day ofCourt in Witness, HonorableWEEK 4(Attorney must sign above and type name below)WEEK 5Attorney(s) forWEEK 6WEEK 7Office and P.O. AddressWEEK 8Telephone No.: Facsimile No.: E-Mail Address:WEEK 9Mobile Tel. No.:FORM CMS-1515F (06/90)American LegalNet, Inc. www.USCourtForms.com
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