COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. STATE OF CALIFORNIA No. : Index WORKERS' COMPENSATION APPEALS BOARD : Calendar No. Plaintiff(s) -against: : : APPLICANT, ORDER APPROVING COMPROMISE & RELEASE CASE NO. JUDICIAL SUBPOENA : VS. Defendant(s) : ...................................................... DEFENDANTS. THE PEOPLE OF THE STATE OF NEW YORK TO The parties to the above-entitled action having filed a Compromise & Release herein, and; For GREETINGS: the reasons set forth in the Compromise & Release and based upon an evaluation of the entire record, the settlement appears adequate and should be approved. The entire medical record is admitted into evidence. WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court The court has considered release of applicant's dependents' rights to death benefits in located at County of determining the adequacy of the Compromise & Release. in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testifycontested evidence as athe substantial possibility the part of the findings as set forth in the offer and give issues and witness in this action on that adverse In view of the of proof could totally bar the applicant's entitlement to any benefits, the inclusion of release of rehabilitation claims is also reasonable and appropriate. Thomas v. Sport Chalet, Inc., 42 CCC 625. Your attorney's comply with this subpoena is punishable as a contempt of court and will make you liable to An failure to fee of $ is reasonable and will be allowed. 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. ORDERED that said Compromise and Release is approved Now therefore, IT IS AWARD is made in favor of: Witness, Honorable Court in County, day of , 20 , one of the Justices of the Applicant in the sum of $ less attorney's fees of $ BALANCE PAYABLE TO APPLICANT (Attorney must sign above and type name below) The Board retains jurisdiction over liens filed to date, self-procured medical, and penalty and interest. Date: Attorney(s) for Workers' Compensation Judge Served by mail on persons shown Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com DIA-65B