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Subpoena DIA WCAB 30 - California

Subpoena Form. This is a California form and can be used in General Workers Comp .
 Fillable pdf Last Modified 10/13/2004
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COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. No. STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS : Calendar DIVISION OF WORKERS' COMPENSATION WORKERS' COMPENSATION APPEALS BOARD : Plaintiff(s) JUDICIAL SUBPOENA -against- Case No. : : : Defendant(s) : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vs. . . . . . . . . . . .. Claimant/Applicant Employer/Insurance Carrier/Defendant (IF APPLICATION HAS BEEN FILED, CASE NUMBER MUST BE INDICATED REGARDLESS OF DATE OF INJURY) THE PEOPLE OF THE STATE OF NEW YORK TO SUBPOENA The People of the State of California Send Greetings to: GREETINGS: YOU ARE HEREBY COMMANDED to appear before a Workers' Compensation Judge of the WORKERS' COMPENSATION APPEALS BOARD OF THE STATE OF CALIFORNIA atbusiness and excuses being laid aside, you and each of you attend before WE COMMAND YOU, that all , the Honorable at the Court located at County of on the day of , , at o'clock. M., to testify in the abovein room , on the day of , 20 , at o'clock in the noon, and at any recessed entitled action. or adjourned date, to testify and give evidence as a witness in this action on the part of the For failure to attend as required, you may be deemed guilty of contempt and liable to pay to the parties aggrieved all losses and damages sustained thereby and forfeit one hundred dollars in addition thereto. This subpoena is issued at request of , Telephone No. 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 andAPPEALS BOARD all damages sustained as a WORKERS' COMPENSATION result of your failure to comply. OF THE STATE OF CALIFORNIA Witness, Honorable Court in County, , one of the Justices of the day of , 20 Secretary, Assistant Secretary, Workers' Compensation Judge Date , (Attorney must sign above and type name below) This subpoena does not apply to any member of the Highway Patrol, Sheriff's Office or city Police Department unless accompanied by notice from the Board that deposit of the witness fee has been made in accordance with Government Code 68097.2, et seq. Attorney(s) for FOR INJURIES OCCURRING ON OR AFTER JANUARY 1, 1990 AND BEFORE JANUARY 1, 1994: If no Application for Adjudication of Claim has been filed, a declaration under penalty of perjury that the Employee's Office and to Labor Code Claim for Workers' Compensation Benefits (Form DWC-1) has been filed pursuant P.O. Address Section 5401 must be executed properly. [SUBPOENA INVALID WITHOUT DECLARATION] Telephone No.: DIA WCAB 30 (Side 1) (Rev. 06/94) Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : DECLARATION FOR INJURIES OCCURRING ON OR AFTER Calendar No. JANUARY 1, 1990 AND BEFORE JANUARY 1, 1994, : FOR WHICH AN APPLICATION FOR ADJUDICATION OF CLAIM HAS NOT BEEN FILED JUDICIAL SUBPOENA Plaintiff(s) -againstSTATE OF CALIFORNIA, County of : : : Case No. The undersigned states: Defendant(s) That he/she is (one of) the attorney(s) of record/representative(s) for the applicant/defendant in the action captioned : . . . . . . . . . . . . . . . . . . Employee's . . . . . . . . . . . . Compensation Benefits (DWC Form 1) has been filed on .the .reverse . hereof, . and .that. .an. . . . . . . . . . .Claim . for . Workers'. . . . in accordance with Labor Code Section 5401 and California Code of Regulations, title 8, section 10120 (Administrative Director's Rules and Regulations), by the alleged injured worker in this action, or, if the worker is deceased, by the dependent(s) of the decedent, and that a true copy of the form filed is attached hereto. THE PEOPLE OF THE STATE OF NEW YORK I declare under penalty of perjury that the foregoing is true and correct. Executed on TO , , at , California. GREETINGS: Signature Address Telephone WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the DECLARATION OF SERVICE STATE party on whose behalf this the OF CALIFORNIA, County of I, the undersigned, state that I served the foregoing Subpoena by showing the original and delivering a true copy thereof, together with a copy of the Declaration in support thereof, to each of the following named persons, personally, at the date and placeWitness, opposite each name. set forth Honorable , one of the Justices of the Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Court in County, Name of Person Served day of , 20 Date Place (Attorney must sign above and type name below) I declare under penalty of perjury that the foregoing is true and correct. Executed on , , at Attorney(s) for , California. Office and P.O. Address Signature DIA WCAB 30 (Side 2) (Rev. 06/94) Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com
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