COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Statement of Employer Payments No. Index : In Reply, Refer to Case No: Date: Prime: Subcontractor: PROJECT NAME: PROJECT CONTRACT NO.: Plaintiff(s) : -against- JUDICIAL SUBPOENA : County/location: HEALTH AND WELFARE Calendar No. : Address, City and Zip : Defendant(s) NAME OF PLAN : ....... ADMINISTRATOR. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . and. Zip. . . . . Address, City . . . . CLASSIFICATION(S) USED CONTRIBUTION PER CLASSIFICATION PER HOUR THE PEOPLE OF THE STATE OF NEW YORK CONTRIBUTIONS: TO WEEKLY_____ NAME OF PLAN MONTHLY_____ PENSION QUARTERLY_____ ANNUALLY_____ Address, City and Zip GREETINGS: ADMINISTRATOR Address, City and Zip WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before CONTRIBUTION PER CLASSIFICATION PER HOUR , at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed CONTRIBUTIONS: WEEKLY_____ MONTHLY_____ QUARTERLY_____ ANNUALLY_____ or adjourned date, to testify and give evidence as a witness in this action on the part of the CLASSIFICATION(S) USED the Honorable VACATION/HOLIDAY NAME OF PLAN Address, City and Zip CLASSIFICATION(S) USED CONTRIBUTION PER CLASSIFICATION PER HOUR 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 Address, City and Zip was issued for a maximum penalty of $50 and all damages sustained as a ADMINISTRATOR result of your failure to comply. Witness, Honorable Court in County, CONTRIBUTIONS: WEEKLY_____ , one of the Justices of the day of , 20 MONTHLY_____ TRAINING QUARTERLY_____ ANNUALLY_____ (Attorney must sign above and type name below) NAME OF PLAN Address, City and Zip ADMINISTRATOR Address, City and Zip CLASSIFICATION(S) USED CONTRIBUTION PER CLASSIFICATION PER HOUR Attorney(s) for Office and P.O. Address CONTRIBUTIONS: WEEKLY_____ MONTHLY_____ QUARTERLY_____ ANNUALLY_____ IF YOU USE OTHER PLANS NOT LISTED ABOVE, YOU MAY USE THE BACK OF THIS FORM TO PROVIDE THIS ADDITIONAL INFORMATION PW 26 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com