COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::BEFORE THE INDUSTRIAL COMMISSION OF ARIZONAIndex No.Calendar No.CLAIM FOR DEPENDENT'S BENEFITS FATALITYJUDICIAL SUBPOENACHECK APPROPRIATE BOX:Plaintiff(s) -against-Defendant(s)SPOUSEPARENTSSPOUSE WITH DEPENDENT CHILDRENOTHER DEPENDENTSDEPENDENT CHILDRENBURIAL EXPENSE ONLY (Must be filed by guardian). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .INFORMATION REGARDING DECEASED: 1.Name of Deceased:Soc. Sec. # *:2.Date of Birth:Date of Death:THE PEOPLE OF THE STATE OF NEW YORK TO3.Date of Injury: (If different from date of death): 4.Deceased's Address:GREETINGS:5.Employer at time of death: Employer's address: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 room6.Briefly state cause of death: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.7.List name and address of health care providers that treated deceased in the last two years and state condition treated:, one of the Justices of theCourt in Witness, Honorableday of, 20 County,(Attorney must sign above and type name below)CLAIM FOR SPOUSAL BENEFITS: (Provide certified copy of marriage certificate.) 1.Your Full Name:Date of Birth:2.Your Address:Attorney(s) for3.Office and P.O. AddressDate of Marriage to Deceased: Place of Marriage: 4.Were You or Deceased Married Previously?No If yes, state details and provide copies of divorceYesdecrees.Telephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.com(Rev. 5/00)COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::5.Did you reside with deceased at time of death?YesNo If living apart provide reason, such as divorced,Index No.divorce pending, annulment, abandonment.Calendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)CLAIM FOR DEPENDENT CHILDREN: (Provide certified copies of birth certificates.) 1.List dependent children:NAMEDATE OF BIRTHRELATIONSHIPTO DECEASEDADDRESS AT TIME OF DEATH. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .THE PEOPLE OF THE STATE OF NEW YORK TO2.Which of these children are still in your care and custody?GREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable3Is a posthumous (unborn) child expected?YesNo If yes provide anticipated date of delivery:,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 roomOTHER DEPENDENTS: 1.Name: 2.Address: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.3., one of the Justices of theRelationship to Deceased: 4.Extent of Dependency:FullPartialPlease give details:Court in Witness, Honorableday of, 20 County,(Attorney must sign above and type name below)DATESIGNATURE OF/OR ON BEHALF OF DEPENDENTAttorney(s) forTELEPHONE NUMBER To be filed at either office of the Industrial Commission:Industrial Commission of ArizonaIndustrial Commission of Arizona Office:TucsonPhoenix800 W. Washington Street2675 E. Broadway Phoenix, Arizona 85007-2922Office:Tucson, Arizona 85716-5342Office and P.O. AddressP. O. Box 19070 Phoenix, Arizona 85005-9070Telephone No.: Facsimile No.: E-Mail Address: The mandatory requirement that the social security number be included in forms filed with the Claims Division or Special Fund Division of the Industrial Commission of Arizona is permitted by Section 7(a)(2)(B) of the Federal Privacy Act of 1974, because the Commission's forms, prescribed under the Commission's Rules in existence prior to January 1, 1975, required disclosure of the social security number. The number is used as a means of identifying all the various records in the Claims Division or Special Fund pertaining to an individual. The use of social security numbers is made necessary because of the large number of persons who have similar names and birth dates, and whose identities can only be distinguished by the social security number. THE INDUSTRIAL COMMISSION COMPLIES WITH THE AMERICANS WITH DISABILITIES ACT OF 1990. IF YOU NEED THIS DOCUMENT IN ALTERNATIVE FORMAT, CONTACT SPECIAL SERVICES AT (602) 542-1829.Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.com
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