SUMMONS - WORKERS' COMPENSATION 3511 C (Rev. 07/08) UNITED STATES OF AMERICA STATE OF ILLINOIS COUNTY OF DU PAGE IN THE CIRCUIT COURT OF THE EIGHTEENTH JUDICIAL CIRCUIT vs ILLINOIS WORKERS' COMPENSATION COMMISSION CASE NUMBER and COPY File Stamp Here SUMMONS WORKERS' COMPENSATION To each Respondent: You are hereby summoned and required to file your appearance on or before in 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. decision or award was rendered on in which a by the Illinois Workers' Compensation Commission for and against WITNESS: CHRIS KACHIROUBAS, Clerk of the Eighteenth Judicial Circuit Court, and the seal thereof, Wheaton, Illinois Date Name: CHRIS KACHIROUBAS PRO SE DuPage Attorney Number: Clerk of the 18th Judicial Circuit Court Attorney for: Address: City/State/Zip: Telephone Number: NOTE: 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. CHRIS KACHIROUBAS, CLERK OF THE 18 th JUDICIAL CIRCUIT COURT © WHEATON, ILLINOIS 60187 - 0707 American LegalNet, Inc. www.FormsWorkflow.com