COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. California Department of Industrial Relations : Calendar No. Division of Workers' Compensation : : JUDICIAL Plaintiff(s) Request to View a WCAB Case FileSUBPOENA -against: Instructions: In order to view a WCAB case file, please complete and submit this form to the clerk at the front counter. Your request will be reviewed by a supervisor and you will be informed of the : decision as soon as possible. Defendant(s) : ...................................................... 1. Please complete the following (please print): Requester Name: THE PEOPLE OF THE STATE OF NEW YORK DWC Authorization # (if any): TO Company Name: Address: GREETINGS: City/State/Zip: WE Telephone: 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 Requester's Business: Nature 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 If you are making this request on behalf of another, please provide the following data about the person or this subpoena is punishable as a contempt of court and will make you liable to Your failure to comply with entity you represent: 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. Name: Company Name:Honorable Witness, Court in County, Address: City, State, Zip: (Attorney must sign above and type name below) 2. , one of the Justices of the day of , 20 Telephone: Nature of Business: Attorney(s) for 3. Please provide the following: WCAB Case Number: Injured Workers' Name: Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: (Please complete reverse side of form) Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com DWC Form AD-1 (New 1/96) COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : California Department of Industrial Relations Division of Workers' Compensation : Index No. Calendar No. Request to View a WCAB Case File : Page JUDICIAL Plaintiff(s) 2 : SUBPOENA -against4. : Please explain why you want this information and the reasons why your client wants this information. : Defendant(s) : ...................................................... THE PEOPLE OF THE STATE OF NEW YORK TO 5. Please read the following and sign as indicated below. NOTE: This Request is a Public Record. A copy of this request will be retained by the DWC GREETINGS: District Office. By making this request you are declaring that you will not use the information you receive for illegal or unlawful purposes. WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the the undersigned, declare under penalty of perjury under the laws of the State of California, Honorable at the Court I, located atreceived pursuant to this request for illegal or unlawful CountyI of that shall not use the information in room , on the day of , correct. , at o'clock in the noon, and at any recessed purposes and that the foregoing is true and20 or adjourned date, to testify and give evidence as a witness in this action on the part of the I agree to replace all the papers in the file in the same order and position as received. I am aware that it is a crime punishable by imprisonment to steal, secrete, remove, Your failure to comply or alter any is punishable as file (Government Code Section destroy, mutilate, deface with this subpoenapaper in the a contempt of court and will make you liable to 6200-6201) 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. Witness, Honorable Court in County, Signature day of , one of the Justices of the , 20 Date ******************************************************************************************************************** (To be completed by the Division of Workers' Compensation only) type name below) (Attorney must sign above and Your request to view the WCAB case file has been granted. Attorney(s) for Your request to view the WCAB case file has been denied because Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com