COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Form 10Calendar No.FORM 10. Statement Concerning DiscriminationJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)UNITED STATES COURT OF APPEALS FOR THE FEDERAL CIRCUIT v. No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .PETITIONER ' S FED. CIR. R. 15( c) STATEMENT CONCERNING DISCRIMINATION INSTRUCTIONS: Select only one of the following statements. Do not alter or add to any of the statements. ( 1)THE PEOPLE OF THE STATE OF NEW YORK TONo claim of discrimination by reason of race, sex, age, national origin, or handicapped condition has been or will be made in this case. ( 2)Any claim of discrimination by reason of race, sex, age, national origin, or handicapped condition raised before the employing agency or the Merit Systems Protection Board or arbitrator has been abandoned or will not be raised or continued in this or any other court.GREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable ( 3)The petition seeks review only of the Merit Systems Protection Board 's or arbitrator 's dismissal of the case for lack of jurisdiction or for untimeliness.,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 room ( 4)The case involves an application to the Office of Personnel Management for benefits. ( 5)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.The case was transferred to this court from a district court and I continue to contest the transfer. Also, answer the following: Have you filed a discrimination case in a United States district court concerning the same matter? Yes NoIn the Equal Employment Opportunity Commission? Yes NoIf so, identify each case. Use extra sheets if needed., one of the Justices of theCourt in Witness, Honorableday of, 20 County, DatesignaturePetitioner 's(Attorney must sign above and type name below)Mail this form with the petition for review or within 14 days of the date of docketing of the petition for review to:Clerk of Court United States Court of Appeals for the Federal Circuit 717 Madison Place, NW Washington, DC 20439Attorney(s) forOffice and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.comMay 1, 2004 Edition
|
Get this form for FREE as a print-only pdf
