COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : COURT OF APPEALS, STATE OF COLORADO 2 East Fourteenth Avenue, Suite 300 Denver, CO 80203 Plaintiff(s) Index No. : Calendar No. : JUDICIAL SUBPOENA _______________________________________________________ , -against: Petitioner (Person/business initiating the appeal) : V. : INDUSTRIAL CLAIM APPEALS OFFICE and Defendant(s) : . . . . ._______________________________________________________ , ................................................. _______________________________________________________ , ___________________________________ Case #: _________________ (List All other parties to the appeal) THE Respondents PEOPLE OF THE STATE OF NEW YORK (to be assigned by court) NOTICE OF APPEAL (C.A.R. 3.1 Worker’s Compensation) TO I. AGENCY INFORMATION • Agency from which judicial review is sought: Industrial Claim Appeals Office WC: ___________________ GREETINGS: case number • Agency II. PROPOSED ISSUES ON APPEAL WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Please give appeal. required , the Honorable a general and advisory list of issues on at the You will be Court to file a detailed opening brief 15 days after you receive located at County of notice that the record from the ICAO has been filed. If you need more space, attach a separate sheet. 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 the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a III. PARTY AND ATTORNEY INFORMATION result of your failure to comply. All parties and the ICAO must be identified and a copy of the notice of appeal must be mailed to each. You may refer to the mailing information on the last page of the ICAO Final Order to find this information. If a party was represented by an attorney, then Witness, Honorable , one you should identify the attorney and that party should be served through the attorney. of the Justices of the Court in County, day of Respondent Employer/Employee: , 20 Attorney for Respondent Employer/Employee: Attorney for Respondent ICAO: (Attorney must sign above and type name below) Office of the (name) (name) Attorney(s) for (address) (address) Respondent Insurance Company Attorney General Human Resources Section 1525 Sherman St., 5th Floor Denver, CO 80203 Attorney for Respondent Insurance Company Office and P.O. Address (name) (address) Notice of Appeal ICAO - WC (name) Telephone No.: Facsimile No.: (address) E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com 03-2004 COURT UNTY . . . . . . . . .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : Index No. IV. APPENDIX : Calendar No. You must attach a complete copy of the ICAO Final Order, including the certificate of service. Plaintiff(s) -against- : JUDICIAL SUBPOENA V. SIGNATURE : You must sign this notice of appeal and provide us with your address and phone number. : Signature of Petitioner By:________________________________ Address of Petitioner : - Sign here - Defendant(s) : . . . . . . . . . Phone. #:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..... . The original and five (5) copies of this Notice of Appeal must be filed with the Clerk of the Court, Colorado Court of Appeals, 2 East 14th Ave., Suite 300, Denver, CO 80203. E PEOPLE OF THE STATE OF NEW YORK CERTIFICATE OF SERVICE You must complete this certificate of service and mail or hand-deliver a complete copy of the notice of appeal to each party listed. EETINGS:hereby certify that a true and correct copy of this NOTICE OF APPEAL, together with complete copies of all I attachments was: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , Honorable Please check the at the Court placed in the United States mail, properly addressed, postage prepaid, or appropriate box located at nty of to,the right. oom on the day of hand-delivered, , at , 20 o'clock in the noon, and at any recessed djourned date, to testify and give evidence as a witness in this action on the part of the to each of the following parties on this date: _________________________ (date of mailing/hand delivery) Division of Employment & Training Employer/Employee (name & address): U.I. Benefits Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to party on 251 East 12th this subpoena was issued for a maximum penalty of $50 and all damages sustained as a whose behalf Avenue lt of your failure to comply. Denver, CO 80203 rt in Witness, Honorable County, , one of the Justices of the day of AND , 20 Insurance Company (name & address): (Attorney must sign above and type name below) Attorney(s) for Office of the Attorney General Human Resources Section 1525 Sherman St., 5th Floor Denver, CO 80203 AND Employer’s/Employee’s Attorney, if any: Office and P.O. Address Telephone No.: Facsimile No.: _____________________________________ By: (Signature of Petitioner) E-Mail Address: Mobile Tel. No.: Notice of Appeal ICAO - WC American LegalNet, Inc. www.USCourtForms.com 03-2004