COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : FILING OFFICE -againstADMINISTRATIVE ACTION STATEMENT Plaintiff(s) Calendar No. : JUDICIAL SUBPOENA : INTERNAL USE ONLY : 1. Identification of the Record to which this FILING OFFICE STATEMENT relates. 1a. RECORD # : 1b. DATE AND TIME RECORD FILED Defendant(s) : ...................................................... 1c. FILE # OF INITIAL FINANCING STATEMENT TO WHICH THE RECORD RELATES THE ABOVE SPACE IS FOR FILING OFFICE USE ONLY 2. Describe the inaccuracy or mistake on the part of the filing office. THE PEOPLE OF THE STATE OF NEW YORK TO GREETINGS: WE 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 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 result of your failure to comply. 3. Describe filing office administrative action taken as a result of inaccuracy or mistake (including date of each action). Witness, Honorable Court in County, , one of the Justices of the day of , 20 (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address FILING CLERK FILING OFFICE COPY — FILING OFFICE ADMINISTRATIVE ACTION STATEMENT Telephone No.: Facsimile No.: DATE THIS FILING OFFICE ADMINISTRATIVE ACTION STATEMENT FILED E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com