COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Plaintiff(s) -against- Calendar No. : JUDICIAL SUBPOENA : : DATE: ____________________ : TO: Deloris L. Jay, CRC, CCM Defendant(s) : . . . . . . . . . . . Vocational .Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Coordinator NH Department of Labor THE PEOPLE OF THE STATE OFREHABILITATION CLOSURE FORM NEW YORK TO EMPLOYEE ______________________________ DATE OF INJURY ______________________________ SOCIAL SECURITY NUMBER ______________________________ EMPLOYER OF INJURY ______________________________ GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before REHABLITATION SPECIALIST ______________________________ , the Honorable at the Court located at County of REFERRAL DATE ______________________________ 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 CLOSURE DATE ______________________________ REASON FOR CLOSURE (Check one): Your RWS: to comply with this subpoena services provided _____ failure Return to work with rehabilitationis 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 _____failure to comply.work with NO rehabilitation services provided your RWN: Return to _____ NRP: No rehabilitation potential Witness, Honorable Court in _____ LSS: Lump sum settlement of County, day , one of the Justices of the , 20 _____ LDH: Labor Department hearing decision _____ BCR: By carrier request (Attorney must sign above and type name below) _____ MMO: Medical management only Attorney(s) for _____ OOO: Other (Relocation, refusal of services, death, etc.) Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com