Illinois > Local County > Dupage > Workers Comp
Summons-Workers Compensation 3511 - Illinois
| Summons-Workers Compensation Form. This is a Illinois form and can be used in Workers Comp Dupage Local County . |
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S UMMONS -WOR KER S COMPE NS ATION 3511 (Rev. 12/04) UNITED STATES OF AMERICA STATE OF ILLINOIS COUNTY OF DU PAGE IN THE CIRCUIT COURT OF THE EIGHTEENTH JUDICIAL CIRCUIT CASE NUM BER PLAINTIFF VS. INDUSTRIAL COMMISSION OF ILLINOIS AND RESPONDENT File Stamp Here SUM M ONS - WOR KERS COM PENSATION TO: Each Respondent: You are hereby summoned and required to file your appearance on or before * in the above entitled proceeding, in the office of the Clerk of the Eighteenth Judicial Circuit Court located at the DuPage Judicial Center, 505 N. County Farm Road, Wheaton, DuPage County, Illinois; and the Illinois Industrial Commission shall, on or before * , certify and file, the above entitled proceeding in the office in the office of the Clerk of this Court, a transcript of the proceedings had before the commission, in Industrial Commission No. , which a decision or award was rendered on by the Industrial Commission of Illinois against WITNESS: CHRIS KACHIROUBAS, Clerk of the Eighteenth Judicial Circuit, and the seal thereof, at Wheaton, Illinois. Dated .Clerk of the Circuit Court NOTE: Pursuant to law, proceedings for judicial review shall be commenced within 20 days of the Name: PRO SE Receipt of Notice of decision of the commission. DuPage Attorney Number: The summons shall be issued by the Clerk of the Court upon written request, returnable on a Attorney for: designated return date*, not less than ten (10) Address: days nor more than sixty (60) days from the date of issuance thereof. City/State/Zip: Telephone: Date of Service (To be inserted by officer on copy left with employer or other person.) CHRIS KACHIROUBAS, CLERK OF THE 18TH JUDICIAL CIRCUIT COURT WHEATON, ILL INOIS 60189-0707 <<<<<<<<<********>>>>>>>>>>>>> 2 SHERIFFS RETURN I certify that I served this summons on defendants as follows: (Check appropriate box, and complete information below) (a) (Individual defendants personal): By leaving a copy and a copy of the complaint with each individual defendant personally. (b) (Individual defendants abode): By leaving a copy and a copy of the complaint at the usual place of abode of each individual defendant with a person of his family, of the age of 13 years or upwards, informing that person of the contents and also by sending a copy of the summons in a sealed envelope with postage fully prepaid, addressed to each individual defendant at his usual place of abode. (c) (Corporation defendants): By leaving a copy and a copy of the complaint with the registered agent, officer or agent of each defendant corporation. (d) (Other services): (e) (Unable to serve): By , Deputy, Badge No. Name of Defendant Name of Defendant Name of Person Name of Person Summons given to Summons given to Sex Race Approx. Age Sex Race Approx. Age Place of Service Place of Service Date of Service Time Date of Service Time Date of Mailing Date of Mailing Sheriff of County By , Deputy
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