COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. APPLICATION FOR PREDETERMINATION : OF INDEPENDENT CONTRACTORCalendar No. STATUS TO ESTABLISH REBUTTABLE PRESUMPTION : Plaintiff(s) JUDICIAL SUBPOENA STATE OF MAINE : Workers' Compensation Board 27 STATE HOUSE STATION AUGUSTA, ME 04333-0027 : -against- TEL: (207) 287-3751 FAX: (207) 287-7198 TDD: (207) 287-6119 : APPLICANT: Defendant(s) : ...................................................... NAME THE PEOPLE OF THE STATE OF NEW YORK TO ADDRESS NUMBER AND STREET CITY GREETINGS: STATE ZIP TELEPHONE NUMBER 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 ______________________________________________(applicant), hereby request a orI,adjourned date, to testify and give evidence as a witness in this action on the part of thepredetermination pursuant to 39-A M.R.S.A. §§ 105 that the relationship between the above-named applicant and the following individual or company is that of contractor/independent contractor within the definition of independent contractor contained in 39-A M.R.S.A. §§ 102(13). 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 POTENTIAL INDEPENDENT CONTRACTOR result of your failure to comply. Witness, Honorable Court in County, , one of the Justices of the day of , 20 NAME ADDRESS NUMBER AND STREET (Attorney must sign above and type name below) CITY STATE ZIP Attorney(s) for TELEPHONE NUMBER Office and P.O. Address Telephone No.: THIS DOCUMENT MAY BE PRODUCED IN ALTERNATIVE FORMATS SUCH AS BRAILLE, Facsimile No.: LARGE PRINT AND AUDIO TAPE. E-Mail Address: Mobile Tel. No.: WCB-261(3/97) American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : (1) : Index No. Calendar No. 1. Please indicate the type of agreement that exists between the Applicant and the Potential : Independent Contractor. JUDICIAL SUBPOENA Plaintiff(s) -against: Written contract _____ (Please attach a copy of the signed contract, and answer the questions that follow.) : Verbal agreement _____ (Please describe the agreement, and answer the questions that : follow). Defendant(s) : ...................................................... 2. How long will the contract or agreement be in effect? THE PEOPLE OF THE STATE OF NEW YORK 3. TO How can the contract or agreement be terminated or discontinued? 4. How will the Potential Independent Contractor be paid? (For example, will the Potential GREETINGS: Independent Contractor be paid by the hour, or is there a set amount that the Potential WE COMMAND YOU, that be paid for completing the contract?) Independent Contractor will 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 Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to 5. Will the Potential Independent Contractor employ assistants to help complete damages sustained as a the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all the contract or result ofagreement? to comply. your failure Witness, Honorable YES _____ Court in County, , one of the Justices of the day of , 20 NO _____ (Attorney must sign above help complete the If “NO”, can the Potential Independent Contractor employ assistants to and type name below) contract or agreement? YES _____ NO _____ Attorney(s) for Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : (2) Index No. : : Plaintiff(s) Calendar No. JUDICIAL SUBPOENA 6. Will the Applicant supply any of the tools and equipment necessary to perform the work? -against: : YES _____ NO _____ : If “YES”, what tools and/or equipment will the Applicant supply?: Defendant(s) : ...................................................... 7. Will the Potential Independent Contractor supply any of the tools and equipment necessary to THE PEOPLE OF THE STATE OF NEW YORK perform the work? TO YES _____ NO _____ GREETINGS: If “YES”, what tools and/or equipment will the Potential Independent Contractor supply?: 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 decides how the work is done from day-to-day? (In other words, does the Applicant or the 8. Who in room , on the day of 20 , decide such things the whatnoon, andto be done o'clock in as Potential Independent Contractor have the, right to at work is at any recessed or adjourned date, to testify and give evidence as a witness in thisto be performed, and how best to perform action on the part of the from day-to-day, the hours between which the work is the work?) Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to _____ APPLICANT 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. _____ POTENTIAL INDEPENDENT CONTRACTOR Witness, Honorable Court in County, day of , one of the Justices of the , 20 9. Please describe the nature of the Applicant’s business. (Attorney must sign above and type name below) Attorney(s) for 10. Please describe the nature of the Potential Independent Contractor’s business. Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : (3) : Index No. Calendar No. 11. Has the Potential Independent Contractor entered into:similar contracts or SUBPOENA JUDICIAL agreements with Plaintiff(s) other individuals which -against-performed at the same time? will be : YES _____ (a) : NO _____ : If “YES”, please describe the similar agreements. Defendant(s) : ...................................................... (b) If “NO”, does the Potential Independent Contractor have the right to enter into similar agreements which OF be performed THE PEOPLE OF THE STATEwill NEW YORK at the same time? TO YES _____ NO _____ 12. Will the Applicant make withholdings from payments made to the Potential Independent GREETINGS: for social security, income taxes, unemployment, or any type of insurance? Contractor WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the HonorableYES _____ at the Court NO _____ 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 givewhat withholdings will thismade by the Applicant. evidence as a witness in be action on the part of the If “YES”, please describe 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 Read your failure to sign below: result of carefully and comply. I hereby certify that the foregoing information is truthful and accurate. the Justices of the Witness, Honorable , one of I understand that should any information contained inof application be found to be intentionally misleading or this Court in County, day , 20 fraudulent, the predetermination of independent contractor status shall be nullified. I further understand that this predetermination of independent contractor status is based upon the information provided in this application and that any changes in these circumstances may nullify the (Attorney must sign above and type name below) predetermination of independent contractor status. I agree to notify the Workers' Compensation Board of any subsequent changes. Attorney(s) for SIGNATURE OF APPLICANT DATE Office and P.O. Address Telephone No.: SIGNATURE OF POTENTIAL INDEPENDENT CONTRACTOR Facsimile No.:DATE E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com