CHRIS KACHIROUBAS, CLERK OF THE 18 th JUDICIAL CIRCUIT COURT 251 WHEATON, ILLINOIS 60187 - 0707 You are hereby summoned and required to file your appearance on or beforein the above mentioned proceeding, in the office of the Clerk of the Eighteenth Judicial Circuit Court, located in the DuPage County Judicial Center, 505 North County Farm Road, Wheaton, Illinois; The Illinois Workers' Compensation Commission shall, on or before certify and file, in the above mentioned proceeding, in the office of the Clerk of this Court, a transcript of the proceeding had before the Commission, in Illinois Workers' Compensation Commission No. in which a decision or award was rendered on by the Illinois Workers' Compensation Commission forand against File Stamp Here 3511 (Rev. /18)SUMMONS - WORKERS' COMPENSATIONSUMMONS WORKERS' COMPENSATIONTo each Respondent:CASE NUMBERvsILLINOIS WORKERS' COMPENSATION COMMISSIONand UNITED STATES OF AMERICA STATE OF ILLINOIS COUNTY OF DU PAGE IN THE CIRCUIT COURT OF THE EIGHTEENTH JUDICIAL CIRCUITWITNESS: CHRIS KACHIROUBAS, Clerk of the Eighteenth Judicial Circuit Court, and the seal thereof, Wheaton, Illinois DateNOTE: Pursuant to law, proceedings for judicial review shall be commenced within twenty (20) days of the receipt of notice of the decision of the Commission. The summons shall be issued by the Clerk of the Court upon written request, returnable on a designated return day, not less than ten (10) nor more than sixty (60) days from the date of issuance.Clerk of the 18th Judicial Circuit Court Name: DuPage Attorney Number: Attorney for: Address: City/State/Zip: Telephone Number: Pro SeEmail: American LegalNet, Inc. www.FormsWorkFlow.com E-E-filing is now mandatory for documents in civil cases with limited exemptions. To e-file, you must first create an accouwith an e-filing service provider. Visit http://efile.illinoiscourts.gov/service-providers.htm to learn more and to select aservice provider. If you need additional help or have trouble e-filing, visit http://www.illinoiscourts.gov/FAQ/gethelp.aspor talk to your circuit clerk's office.CHRIS KACHIROUBAS, CLERK OF THE 18 th JUDICIAL CIRCUIT COURT 251 WHEATON, ILLINOIS 60187 - 0707 3511 (Rev. /18)SUMMONS - WORKERS' COMPENSATIONNameRespondentAddressCity, State, ZipOnin accordance with law I mailed a copy of this summons, postage prepaid, to the office of the Illinois Workers' Compensation Commission and to the following parties in interest or their attorney or attorneys of record: Name Name Name City, State, Zip Address Name Address City, State, Zip City, State, Zip Address Name Address City, State, Zip City, State, Zip Address Name Address City, State, Zip Date Clerk of the Circuit Court American LegalNet, Inc. www.FormsWorkFlow.com