STATE OF ILLINOIS ) ) COUNTY OF __________________) ILLINOIS WORKERS COMPENSATION COMMISSION DEDIMUS POTESTATEM __________________________________________ Case # ________ WC ____________________ Employee/Petitioner v. __________________________________________ Employer/Respondent TO: Because it has been represented to us that each of the individuals listed below: (List each name and address) _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ is a necessary witness in this case and cannot appear at the Commission hearing, we appoint you to examine each witness under oath and to take his or her deposition in response to all oral ____ written questions ____ posed by the petitioner or respondent at the following time and place: _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ and to certify each deposition to: Data Entry Unit, Illinois Workers Compensation Commission, 100 W. Randolph St. #8-200, Chicago, IL 60601. ___________________________________________________ ____________________________ Signature of arbitrator or commissioner Date IC33 12/04 100 W. Randolph St. #8-200 Chicago, IL 60601 312/814-611 Toll-free 866/352-3033 Web site: www.iwcc.il.gov Downstate offices: Collinsville 618/346-3450 Peoria 309/671-3019 Rockford 815/987-7292 Springfield 217/785-7084 American LegalNet, Inc. www.USCourtForms.com>>>> 2 PROOF OF SERVICE If the person who signed the Proof of Service is not an attorney, this form must be notarized. I, ________________________________ , affirm that I delivered _____ mailed with proper postage _____ in the city of _________________________________ a copy of this form at ___________ on ___________________ to each party at the address(es) listed below. ____________________________________________ Signature of person completing Proof of Service Signed and sworn to before me on __________________ ___________________________________________ Notary Public IC33 page 2 American LegalNet, Inc. www.USCourtForms.com