COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Plaintiff(s) -against- Calendar No. : JUDICIAL SUBPOENA : BEFORE THE IOWA WORKERS’ COMPENSATION COMMISSIONER : ________________________________________________________________________ : : : Defendant(s) : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . :. . . . . . . . . . . . . . . . Claimant, : : : File No. _____________ THE PEOPLE OF THE STATE OF NEW YORK vs. : : APPLICATION TO DEFER TO : : PAYMENT OF FILING FEES, Employer, : : FINANCIAL AFFIDAVIT AND ORDER GREETINGS: : and : WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before : at the , the Honorable Court located at : County of : , 20 in room , on the day of , 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 Insurance Carrier, : Defendants. : _________________________________________________________________________ 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 I, your failure to comply. result of the undersigned, hereby request the Iowa Workers’ Compensation Commissioner to accept for filing my Original Notice and Petition without prepayment of filing fee(s). I hereby state that if I am unable to defer the filing fee(s) in this matter, I would be unable to maintain Witness, Honorable , one of the Justices of the this action, and there is no reasonable alternative means for procuring the filing fee(s). I Court in County, day of , 20 understand that if the Original Notice and Petition is accepted for filing without prepayment of the filing fee(s), provision for the payment of the filing(s) must be included in any settlement submitted to the Workers’ Compensation Commissioner for approval, or taxed as costs as (Attorney must sign above and type name below) part of a hearing on my petition. In support of my request, I hereby submit the following affidavit under oath (attach Attorney(s) for additional sheets if necessary). Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Plaintiff(s) Calendar No. : JUDICIAL SUBPOENA Current mailing address:_____________________________________________ -against: Current phone number:______________________________________________ Age:________________ : Marital status: Single______Married_______Divorced_______Widow(er)_______ : Name of spouse:____________________Live with spouse? Yes____No____ Defendant(s) : If. no, .length. of .separation. . . . . . spouse:_______________________________ . . . . . . . . . . . . . . . . . . . from . . . . . . . . . . . . . . . . . . . . . . . . . Number and ages of dependents:_______________________________________________________________ THE PEOPLE OF THE STATE OF NEW YORK INCOME: Your occupation:_______________________ TO Are you presently working? Yes____ No____ If yes: Present Employer:_____________________________ Address:______________________________________ GREETINGS: Weekly take-home earnings: $______________ Weekly gross YOU, that $______________ WE COMMAND earnings: all business and excuses being laid aside, you and each of you attend before Earned income for past 12 months: the , the Honorable at $___________ Court If no: located at County of Are you currently receiving weekly workers’ any kind? Yes____No____ o'clock in the in compensation, benefits of day of room on the , 20 , at noon, and at any recessed If yes, to testify $_________ or adjourned date,amount: and give evidence as a witness in this action on the part of the Total received in last 12 months: $___________________ Are you currently receiving any other kind of disability income, such as sick leave, social security disability, or private disability Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to insurance payments? If so, state amount: $_________per________ the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a Are you receiving child support for any dependents?______________ result of your failure to comply. If so, how much? $______________per____________________. Witness, Honorable , of of the Justices of the List all other sources and amounts of income, in your name, nameone spouse or jointly shared with another, including spouse’sday of (net wages), pensions, bonds, stocks, securities, salary Court in County, , 20 private business, farming, insurance, retirement benefits, social security benefits, lawsuits or settlements, gifts or others:______________________________. Unemployment compensation, heating assistance, food stamps, ADC or and type name below)in (Attorney must sign above welfare relief, your name, spouse’s name or jointly shared with another: $_________per __________ List any anticipated tax refunds in the next 6 months and the amount thereof:_______ Attorney(s) for Whether or not you are presently working, state your income from all sources for the past 12 months: $______________________. Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: 2 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : ASSETS: Index No. Calendar No. : JUDICIAL SUBPOENA Bank with:____________________________Address:____________________________ Plaintiff(s) Balance personal bank accounts (checking and savings): -against: $_____________ Balance accounts in name of spouse: $________________ : Balance joint accounts with spouse: $_________________ Balance joint accounts with any other person: $_________ : Defendant(s) : List. the .amount .of. cash. currently. in .your. possession .or. available to you, including cash on .. ... ....... . .... ........ .. ... ........... . .. your person, at your place of residence, in safety deposit boxes, or in any other location: $________________________________ THE PEOPLE OF THE STATE OF NEW YORK Real Estate: Property 1: Type (residence, farm, etc): __________________ Address or location: __________________________ Market value: ________________________________ Insured value:________________________________ Insured with: _____________________________ GREETINGS: Address:__________________________________ Tax value:___________________________________ WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable When purchased: ____________________________ at the Court Purchase price: ______________________________ located at County of Present owners of in room , on the day besides yourself: , ___________ in the , 20 at o'clock noon, and at any recessed or adjourned date,____________________________________________of the to testify and give evidence as a witness in this action on the part Amount of mortgages or liens on property: ______________________________ Is this a homestead? Yes ____ No ____ TO 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 Property 2: Type (residence, farm, etc.): __________________ result of your failure to comply. Address or location: _________________________ Market value: _______________________________ Witness, Honorable , one of the Justices of the Insured value:_______________________________ Court in County, day of , 20 Insured with:___________________________ Address:_______________________________ Tax Value:__________________________________ (Attorney must sign above and type name below) When purchased:____________________________ Purchase price:______________________________ Present owners besides yourself: _____________ Attorney(s) for ____________________________________________ Amount of mortgages or liens on property: __________________________________ Is this a homestead? Yes ____ No ____ Office and P.O. Address If more than two properties are owned, list others on a separate sheet and attach to this form. Is such a sheet attached? Yes_____ No____ Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: 3 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Calendar No. Motor vehicles: Give make, year, present value, amount owing thereon, if any, and whether registered or titled in your name, name of spouse or jointly with another of all vehicles in which you : have an ownership interest: JUDICIAL SUBPOENA Plaintiff(s) -against: Vehicle 1: Description_______________________________ Value $____________ Emcumbrance: $_________________ : Lienholder: _____________________ Address: _______________________ : Vehicle 2: Description________________________________ Defendant(s) : . . . . . . . . . . . . . . . . . . . . Value. $ .___________ . . . . . . . . . . . . . $ __________________ . . . . . . . . . . . . . . . . . . Encumbrance . Lienholder: ______________________ Address: ________________________ THE PEOPLE your name, in the NEW YORK Other assets inOF THE STATE OFname of your spouse, or jointly owned with someone else, including furniture, appliances, televisions, stereos, videotape equipment, photographic cameras, jewelry, furs, trust funds, notes, bonds, stocks, savings certificates, securities, cash value of life insurance, TO equipment or machines, boats, aircraft, motorcycles, campers or recreational vehicles, coin or stamp or any other collections with a recognized market value, livestock, purebred animals, harvested or unharvested crops, etc. and value of each: GREETINGS: ________________________________________________________________________________ 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 a beneficiary or heir in the estate of a person deceased? of Are you Yes___ No___ 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 Does anyone owe you money or have any property belonging to you? If so, give details in full:___________________________________- 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. Do you have a judgment against anyone? If yes, give name, date, court and amount: ________________________________________________________________________________ Witness, Honorable , one of the Justices of the Court in County, day of , 20 EXPENSES: Average monthly living expense: (Attorney must sign above and type name below) Food: $________________per___________ Housing: $_____________per___________ Utilities/telephone: $____________per__________ Attorney(s) for Clothing: $____________per____________ Transportation: $_______________per__________ Medical (paid by you): $_________per__________ Office and P.O. Address Installment payments: $_________per__________ Telephone No.: $__________per___________ Facsimile No.: Other: $__________________________________________ E-Mail Address: Mobile Tel. No.: Payable to:___________________________ 4 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Plaintiff(s) -against- Calendar No. : JUDICIAL SUBPOENA : : I, the undersigned, being duly sworn under oath, certify under penalty of perjury and : pursuant to the laws of the State of Iowa that the foregoing statements are true and correct to the best of my knowledge, and are made in support of my request that my Original Notice Defendant(s) : ...................................................... and Petition be filed without payment of a filing fee at the time of filing. I understand that a knowingly false statement in this affidavit may constitute a fraudulent practice under Iowa THE section OF THE STATE OF subject me Code PEOPLE 714.8(2) and may NEW YORK to criminal penalties, including imprisonment, fine or both. I also hereby authorize the Iowa Workers’ Compensation Commissioner or any of TO the Commissioner’s designees to investigate any statements contained herein, and I hereby waive any privilege and release any information to the Commissioner or the Commissioner’s GREETINGS: designees to facilitate an investigation of the truth of this affidavit. I further state that I am the WE COMMAND YOU, that all that I and read being laid Application and understand claimant in the above-entitled action,businesshaveexcusesthe aboveaside, you and each of you attend before the Honorable at the Court its contents, and that the statementsat contains are true to the best of my knowledge. located it 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 ______________________________________ Claimant 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 failuresworn to by ___________________________________ before me, a Subscribed and to comply. Notary Public, this _____ day of ________________________________, ____. Witness, Honorable Court in County, , one of the Justices of the day of , 20 ______________________________________ Notary Public for the Stateand type name below) (Attorney must sign above of Iowa Attorney(s) for Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: 5 American LegalNet, Inc. www.USCourtForms.com , COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : ORDER Plaintiff(s) -against- Calendar No. : JUDICIAL SUBPOENA : Claimant’s request for deferral of filing fee(s) is approved. Claimant’s Petition and Original : Notice may be filed without prepayment of filing fee(s). Payment of the filing fee(s) shall be deferred until final disposition of this proceeding. : Defendant(s) : ...................................................... Signed and filed this ________day of _______________________, __ ___. THE PEOPLE OF THE STATE OF NEW YORK ______________________________________ TO DEPUTY WORKERS’ COMPENSATION COMMISSIONER GREETINGS: Claimant’s request for deferral of filing fee(s) is denied. Claimant shall forward the WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before appropriate filing fee(s) within 14 days of this Order, or claimant’s Petition will be dismissed the Honorable at the Court located at County of without prejudice and without entry of further order. 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 Signed and filed this ________day of _______________________, __ ___. 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. DEPUTY WORKERS’ COMPENSATION Witness, Honorable COMMISSIONER Court in County, , one of the Justices of the day of , 20 The information provided will be open for public inspection under Iowa Code § 22.11. (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address 14-0075 (7/99) Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: 6 American LegalNet, Inc. www.USCourtForms.com ,