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Interrogatories From Plaintiff To Defendant Form. This is a Kansas form and can be use in 3rd Judicial District (Shawnee County) Local District Court.
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Tags: Interrogatories From Plaintiff To Defendant, Kansas Local District Court, 3rd Judicial District (Shawnee County)
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:
Index No.
:
:
F 3.201(2)A
Plaintiff(s)
Calendar No.
JUDICIAL SUBPOENA
-against(Interrogatories from Plaintiff to :
Defendant)
1.
:
Please state your full name, present address, date of birth, place of birth, social security
:
number and any other name or aliases that you have gone by and dates when so known.
Defendant(s)
:
......................................................
ANSWER:
THE PEOPLE OF THE STATE OF NEW YORK
2.
With regard to the automobile in which you were the operator or passenger at the time
TO
of the occurrence which is the subject matter of this lawsuit, please state:
GREETINGS:
a)
Whether you were the operator or passenger;
b)
The make and business the automobile;
WE COMMAND YOU, that all model ofand excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
c)
The license number of the automobile;
located at
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
or adjourned date,d) testify andfull name, present or last this actionaddresspart of the
to
The give evidence as a witness in known on the and telephone number
of the owner of the automobile; and
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
e)
the party on whose behalfIf thesubpoena waswas notfor a maximum penalty of $50 and all damages sustained as a
this automobile issued owned by you, the relationship between
result of your failure to comply.
you and the owner including a description of the use of such automobile at the
Witness, Honorable
time
Court in
County, of the occurrence.
day of
, one of the Justices of the
, 20
ANSWER:
(Attorney must sign above and type name below)
3.
Did the mechanical condition or operational status offor automobile identified in
the
Attorney(s)
interrogatory number 2 cause or contribute to cause the occurrence which is the subject matter of this
lawsuit? If yes, please state:
Office and P.O. Address
a)
Identify the condition or operation involved;
b)
Describe with particularity how the condition or operation caused
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
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:
or contributed to cause the occurrence; andJUDICIAL SUBPOENA
Plaintiff(s)
c)
-againstIdentify each supporting document. :
:
ANSWER:
:
Defendant(s)
:
......................................................
4.
With regard to repairs to or the maintenance of the automobile identified in response
to interrogatory number 2, please state:
THE PEOPLE OF THE STATE OF NEW YORK
a)
A complete description of all repairs or maintenance;
b)
The full name, present or last known address and telephone
TO
number of the person who performed the repairs or maintenance; and
GREETINGS:
c)
Identify all documents (including records, repair and each of you attend
WE COMMAND YOU, that all business and excuses being laid aside, you bills, statements or before
,
the Honorable
at the
Court
logs) regardingat repairs or maintenance.
located the
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
ANSWER:
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
5.
Were you at the time was issued for a maximum subject matter of all
the party on whose behalf this subpoena of occurrence which is the penalty of $50 and thisdamages sustained as a
result of your failure to comply.
lawsuit performing any job, task, undertaking for any person other than yourself? If your
Witness, Honorable
Court in answer is yes, please state: of
County,
day
a)
b)
, one of the Justices of the
, 20
The full name, present or last known address and telephone
number of the person for whom(Attorney must sign above and type name job, task
you were performing such below)
or undertaking; and
A description of the job, task or undertaking which you were
performing.
Attorney(s) for
ANSWER:
Office and P.O. Address
6.
Describe with particularity your education, training and experience to drive or operate
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
a commercial motor vehicle on the date of the occurrence which is the subject matter of this lawsuit
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including any apprenticeship, certification or licensure.
Plaintiff(s)
ANSWER:
-against-
Calendar No.
JUDICIAL SUBPOENA
:
:
7.
:
Please give the full name, present or last known address and telephone number of all
Defendant(s)
:
......................................................
occupants of your automobile at the time of the occurrence which is the subject matter of this lawsuit.
ANSWER:
THE PEOPLE OF THE STATE OF NEW YORK
TO
8.
Please state whether at the time of the occurrence which is the subject matter of this
lawsuit:
GREETINGS:
a)
You were licensed to operate a motor vehicle;
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
b)
The state issuing such license;
located at
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
or adjourned date,c) testify and give evidence as a witness expiration date of such license; and
to
The identification number and in this action on the part of the
d)
The nature of any and all restrictions on such license.
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
ANSWER:
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.
Witness, Honorable
, one of the Justices of the
Please state the circumstances surrounding your operation of the automobile at the
Court in 9.
County,
day of
, 20
time of the occurrence which is the subject matter of this lawsuit, including:
(Attorney must sign above and type name below)
a)
The location where you were going:
b)
The purpose of the trip; and
c)
The location where you had been prior to the collision and your route
Attorney(s) for
of travel prior to the occurrence which is the subject matter of this
Office and P.O. Address
lawsuit.
ANSWER:
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
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Plaintiff(s)
10.
Calendar No.
:
JUDICIAL SUBPOENA
-against:
Please describe in sequential order your activities from eight hours before to two hours
:
after the occurrence which is the subject matter of this lawsuit, including locations; arrival and
:
departure times; and give the full name, present or last known address and telephone number of all
Defendant(s)
:
......................................................
persons who have knowledge of your activities.
ANSWER:
THE PEOPLE OF THE STATE OF NEW YORK
TO
11.
State the full name, present or last known address and telephone number of all persons
who witnessed or claim to have witnessed the occurrence which is the subject matter of this lawsuit.
GREETINGS:
ANSWER:
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,State the full name, present or last known address andon the part of the of all persons
to testify and give evidence as a witness in this action telephone number
12.
believed or known by you who has or claims to have knowledge concerning any of the issues raised
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
by the pleadings, include subpoena was issued for a maximum penalty of $50 and such person has
the party on whose behalf this in your answer the subject matter about which each all damages sustained as a
result of your failure to comply.
knowledge.
Witness, Honorable
Court in ANSWER:County,
13.
, one of the Justices of the
day of
, 20
(Attorney must sign above and type name below)
State the full name, present or last known address and telephone number of all persons
believed or known by you who has or claims to have heard Attorney(s) for
the plaintiff make any statement, remark
or comment concerning the occurrence which is the subject matter of this lawsuit, include in your
answer a complete factual description of the substance of each statement, remark or comment.
Office and P.O. Address
ANSWER:
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
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14.
Index No.
Calendar No.
:
Please state whether you have obtained a statement, whether orally or in writing, from
JUDICIAL SUBPOENA
Plaintiff(s)
-against:
any person (including the plaintiff and the defendant) who has or claims to have knowledge
:
concerning the occurrence which is the subject matter of this lawsuit or any of the issues raised by
:
the pleadings, indicating:
Defendant(s)
:
......................................................
a)
State the full name, present or last known address and telephone
number of each person to whom each such statement was made or given;
THE PEOPLE OF THE STATE OF NEW YORK
b)
The date of each such statement;
c)
The form of each such statement, whether oral, in writing,
TO
stenographic transcription or otherwise;
GREETINGS:
d)
State the full name, present or last being laid aside, you and each of
WE COMMAND YOU, that all business and excuses known address and telephone you attend before
,
the Honorable
at the
Court
numberlocated atperson now having possession or custody of each
of each
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
or adjourned date, to testify andstatement; andas a witness in this action on the part of the
such give evidence
e)
A complete factual description of the substance and content of each
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalfsuch subpoena was issued for a maximum penalty of $50 and all damages sustained as a
this statement.
result of your failure to comply.
ANSWER:
Witness, Honorable
Court in
County,
15.
, one of the Justices of the
day of
, 20
With regard to any lawsuits which have been filed against you by other persons for
(Attorney must sign above and type name below)
the incident which is the subject matter of this lawsuit, please state:
a)
The date it was filed, place it was Attorney(s) for in which it was filed and
filed, the court
its docket number, and the judgment or settlement reached;
b)
State the full name, present or last known address and telephone
Office and P.O. Address
number of each person who testified at the trial or gave a deposition; and
c)
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
State the full name, present or last known address and telephone
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number of each expert witness who testifiedJUDICIAL SUBPOENA
on your behalf.
Plaintiff(s)
ANSWER:
-against-
:
:
16.
:
Do you, or anyone acting on your behalf, have a copy of any record or testimony
Defendant(s)
:
......................................................
taken at a prior hearing involving the occurrence which is the subject matter of this lawsuit? If yes,
please state:
THE PEOPLE OF THE STATE OF NEW YORK
a)
The date and nature of the hearing;
b)
The full name, present or last known address and telephone
TO
number of the person who recorded the testimony; and
GREETINGS:
c)
The full name, present and excuses being laid and telephone
WE COMMAND YOU, that all business or last known address aside, you and each of you attend before
,
the Honorable
at the
Court
numberlocated at
of the present custodian of the record of testimony.
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
ANSWER:
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
17.
Have you entered into any agreement, compromise or arrangement with any person
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.
regarding the occurrence which is the subject matter of this lawsuit? If your answer is yes, please
Witness, Honorable
state:
Court in
County,
a)
, one of the Justices of the
day of
, 20
The full name, present or last known address and telephone
number of each such person;
(Attorney must sign above and type name below)
b)
The nature of such arrangement or Attorney(s) for
agreement;
c)
Whether or not such arrangement or agreement is oral or written; and,
d)
The date such arrangement or agreement was made.
Office and P.O. Address
ANSWER:
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
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18.
Index No.
Calendar No.
:
With respect to any and all violations of the law with which you have been charged,
JUDICIAL SUBPOENA
Plaintiff(s)
-againstconvicted or pleaded guilty to, including violations as a result:of the occurrence which is the subject
:
matter of this lawsuit, please state:
a)
:
The date of each violation;
Defendant(s)
:
......................................................
b)
The crime or violation to which you were charged;
c)
The county and state in which the violation occurred;
THE PEOPLE OF THE STATE OF NEW YORK
d)
The plea entered and/or outcome of each violation;
e)
The case number and court the violation was heard in; and
f)
Whether the testimony at trial of the violation was recorded in any
TO
GREETINGS:
manner.
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 ofANSWER:
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
19.
With respect to any and all automobile accidents in which you have been involved
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
(whether whose behalf this subpoena was the past ten (10) years, please state and all damages sustained as a
the party onas a driver or passenger) within issued for a maximum penalty of $50 the date and location
result of your failure to comply.
of each such occurrence, including the street address, city, county and state.
Witness, Honorable
Court in ANSWER:County,
20.
, one of the Justices of the
day of
, 20
(Attorney must sign above and type name below)
With respect to any and all physical infirmity, disability or sickness from which you
suffered at the time of the occurrence which is the subjectAttorney(s) for please state:
of this lawsuit,
a)
A complete factual description of each condition, including its
nature, extent and severity;
b)
Office and P.O. Address
The duration of time, in months and days, that you had any such
condition prior to this occurrence;
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
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c)
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:
Any and all medical or hospital examination or treatment you had
JUDICIAL SUBPOENA
Plaintiff(s)
-againstreceived for each condition including :the date of each examination
or treatment;
d)
:
:
The name and business address of any and all doctors or hospitals
Defendant(s)
:
......................................................
involved in the examination, treatment or care of each condition; and
e)
Your medical history as it relates to each condition.
THE PEOPLE OF THE STATE OF NEW YORK
ANSWER:
TO
21.
GREETINGS:
With respect to any and all alcoholic beverages or drugs or medications which you
ingested within twenty-four (24) hours before the occurrence which is the subject matter of this before
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend
,
the Honorable
at the
Court
lawsuit,
located at
County of please state:
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
or adjourned date,a) testify and type evidence as a witness in this action on the part of the or medication
to
The give and amount of each alcoholic beverage, drug
ingested;
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
b)
the party on whose behalfThe subpoena was issued foralcoholic beverage,ofdrug and all damages sustained as a
this date and time each a maximum penalty $50 or medication was
result of your failure to comply.
ingested;
Witness, Honorable
, one of the Justices of the
c) County, address and business name, if any, of the location where each
The
Court in
day of
, 20
alcoholic beverage, drug or medication was ingested; and
d)
(Attorney must sign above and type name below)
The full name, present or last known address and telephone
number of all persons who were present when for ingested each
you
Attorney(s)
alcoholic beverage, drug or medication.
ANSWER:
22.
Office and P.O. Address
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
With respect to any and all glasses or contact lenses which you wear, please state:
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a)
Index No.
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The full name, present or last known :
address and telephone
JUDICIAL SUBPOENA
Plaintiff(s)
-against:
number of who prescribed such eye glasses or contact lenses;
:
b)
The date such eye glasses or contact lenses were prescribed;
c)
The date your eyes were last examined;
:
Defendant(s)
:
......................................................
d)
The full name, present or last known address and telephone
number of the person who conducted such examination; and
THE PEOPLE OF THE STATE OF NEW YORK
e)
Whether you were wearing such eye glasses or contact lenses at the
TO
time of the occurrence which is the subject matter of this lawsuit.
ANSWER:
GREETINGS:
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
Were you at fault for the occurrence which is the subject matter of this lawsuit? If yes,
located at
County of23.
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
orfor each occasion when you give evidence as a witness in occurrence, please state:
adjourned date, to testify and admitted your fault for the this action on the part of the
a)
The date and location of the occasion;
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
b)
the party on whose behalfThe full name,was issued for a known address and telephoneall damages sustained as a
this subpoena present or last maximum penalty of $50 and
result of your failure to comply.
number of each person present when the acknowledgment or admission
Witness, Honorable
of fault was made; and
Court in
County,
day of
c)
24.
, 20
With particularity, the substance of the acknowledgment or admission of
fault.
ANSWER:
, one of the Justices of the
(Attorney must sign above and type name below)
Attorney(s) for
Describe in detail each act or omission on the part of plaintiff or any other person you
Office and P.O. Address
contend constituted negligence that was a contributing cause of the occurrence which is the subject
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
matter of this lawsuit. Identify in your response all documents which support your claim.
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ANSWER:
Plaintiff(s)
-against-
25.
Calendar No.
:
JUDICIAL SUBPOENA
:
:
With regard to all defenses (including affirmative defenses) which you claim to
plaintiff’s Petition, please state:
:
Defendant(s)
:
......................................................
a)
List each such defense;
b)
All facts which support each such defense;
THE PEOPLE OF THE STATE OF NEW YORK
c)
The full name, present or last known address and telephone
TO
number of all persons who have knowledge of the facts which
support each defense;
GREETINGS:
d)
List all that all business and any way support each you and and
WE COMMAND YOU, documents which inexcuses being laid aside,defense; each of you attend before
,
the Honorable
at the
Court
e)
The full name,at
located present or last known address and telephone
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 insuchaction on the part of the
number of the custodian of each this document.
ANSWER:
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.
26.
With respect to any and all expert witnesses you anticipate calling to testify on your
Witness, Honorable
, one of the Justices of the
behalf
Court in at trial, identify each witness, of provide a ,complete description of his/her qualifications as
County,
day and
20
an expert, the subject on which the expert is expected to testify, the substance of the facts and
(Attorney must sign above and type name below)
opinions to which the expert is expected to testify, and a summary of the grounds for each opinion.
ANSWER:
27.
Attorney(s) for
With respect to any and all witnesses you anticipate calling to testify on your behalf
Office and P.O. Address
at trial, please state the full name, present or last known address and telephone number of each
witness.
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
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ANSWER:
Plaintiff(s)
-against-
28.
Calendar No.
:
JUDICIAL SUBPOENA
:
:
For each inspection, examination, evaluation or survey of the scene of the incident
:
describe in plaintiff’s petition, please state:
Defendant(s)
:
......................................................
a)
The date of each inspection, examination, evaluation or survey;
b)
The full name, present or last known address and telephone
THE PEOPLE OF THE STATE OF NEW YORK
number of all persons present at each inspection, examination,
TO
evaluation or survey; and
GREETINGS:
c)
Identify all documents regarding each inspection, examination,
evaluation or survey.
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 ofANSWER:
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
29.
Please state whether you have possession or control or knowledge of the existence
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
of any on whose behalf this subpoena was issued for a maximum penalty of $50 and or other written
the partymaps, pictures, photographs, videotapes, drawings, diagrams, measurementsall damages sustained as a
result of your failure to comply.
or recorded descriptions which in any way concern the occurrence which is the subject matter of this
Witness, Honorable
lawsuit;
Court in and if so, indicate:
County,
, one of the Justices of the
day of
, 20
a)
The nature of the item;
b)
The specific subject matter of the item;
c)
The date, time and location the item was madefor prepared;
or
Attorney(s)
d)
The full name, present or last known address and telephone
(Attorney must sign above and type name below)
number of the person making or preparing the item; and
Office and P.O. Address
e)
The full name, present or last known address and telephone
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
number of the person now having possession or custody of each such item.
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:
ANSWER:
Plaintiff(s)
-against-
30.
Calendar No.
:
JUDICIAL SUBPOENA
:
:
With respect to any and all policies of insurance, including primary and excess
:
insurance policies, which may provide coverage for the damages sought in plaintiff’s Petition, please
Defendant(s)
:
......................................................
state:
a)
The name of each insurance company providing coverage;
THE PEOPLE OF THE STATE OF NEW YORK
b)
The extent of coverage provided by each policy of insurance, including
TO
coverage for both personal injury and property damage;
GREETINGS:
c)
The policy number of each policy of insurance; and
d)
The effective date of each excuses insurance.
WE COMMAND YOU, that all business andpolicy ofbeing laid aside, you and each of you attend before
,
the Honorable
at the
Court
located at
County ofANSWER:
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
31.
Please state the names, addresses and telephone numbers of any licensed investigators,
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
private investigators or private eyes who have been engaged pursuant $50 and all damages sustained as a
the party on whose behalf this subpoena was issued for a maximum penalty of to K.S.A. 60-226 for the
result of your failure to comply.
purposes of recording the activities, information, statements or comments of the Plaintiff. For each,
Witness, Honorable
, one of the Justices of the
include
Court in the dates the individual was hired, the dates of surveillance or inquiries, the places of
County,
day of
, 20
surveillance or inquiries and the person spoken to regarding the plaintiff.
(Attorney must sign above and type name below)
ANSWER:
Attorney(s) for
Office and P.O. Address
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
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COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
:
:
II. Medical Malpractice
Plaintiff(s)
-against-
32.
Index No.
Calendar No.
JUDICIAL SUBPOENA
:
:
Please list the names of all persons known to you or to your representatives who
:
investigated the allegations of deviation of standard of care of plaintiff.
Defendant(s)
:
......................................................
a)
For each person listed, please state whether their investigations began
prior to or subsequent to the time that you retained counsel for this matter.
THE PEOPLE OF THE STATE OF NEW YORK
b)
For each person listed above, please state whether there exists a record
TO
of such investigation, either by audio, video, notes or electronic media;
and for each person, state how such investigation was memorialized.
GREETINGS:
ANSWER:
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,Please list all give evidence hold witness in this action on the part ofdate you received it
to testify and degrees you as a and specify for each degree the the
33.
and the school from which it was received.
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
ANSWER:
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.
Witness, Honorable
, one of the Justices of the
Please give the name of address of 20
Court in 34.
County,
day and
, every hospital at which you served as an intern
and/or a resident, and specify as to each such hospital the inclusive dates of your employment, your
(Attorney must sign above and type name below)
title or titles in a specialty field, if any, within which you worked.
ANSWER:
35.
Attorney(s) for
Please set forth the name and publisher of each medical journal, magazine, newsletter,
Office and P.O. Address
circular and other similar publication to which your subscribe to and or regularly read to keep up with
developments in the medical fields.
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
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COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
:
ANSWER:
Plaintiff(s)
-against-
36.
Calendar No.
:
JUDICIAL SUBPOENA
:
:
Please list the states, providence, and foreign countries in which you are or have ever
:
been professionally licensed and for each such state, providence or foreign country, indicate the
Defendant(s)
:
......................................................
inclusive dates of your licenser and your license number.
ANSWER:
THE PEOPLE OF THE STATE OF NEW YORK
TO
37.
Has any professional license held by you ever been suspended or revoked, or has
renewal ever been refused? If so, please give the details of each such suspension, revocation or
GREETINGS:
refusal of renewal, including in your all businessname of the being laid aside, you and each country, the before
WE COMMAND YOU, that answer the and excuses state, providence or foreign of you attend
,
the Honorable
at the
Court
date of suspension, revocation located at of renewal, the reason therefore and the date, if any, upon
or refusal
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
orwhich yourdate, to testifyreinstated.
adjourned license was and give evidence as a witness in this action on the part of the
ANSWER:
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.
38.
Have you ever been certified by any American Medical Specialty Board? If so, please
Witness, Honorable
, one of the Justices of the
state the
Court in name of each Board and indicate as to each the date on which you were certified.
County,
day of
, 20
ANSWER:
(Attorney must sign above and type name below)
39.
Are you eligible to take the examination Attorney(s) for given by any American
for certification
Medical Specialty Board? If so, please state as to each eligibility:
(a)
The requirements and the name of the specialty board;
(b)
Why you have not yet taken the examination and the date you became
Office and P.O. Address
eligible to take the examination.
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
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COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
:
ANSWER:
Plaintiff(s)
-against-
40.
Calendar No.
:
JUDICIAL SUBPOENA
:
:
Please list each date on which you took an examination required by any American
:
Medical Specialty Board, and for each such date indicate the nature and scope of the examination and
Defendant(s)
:
......................................................
state whether you passed or failed.
ANSWER:
THE PEOPLE OF THE STATE OF NEW YORK
TO
41.
Are you now or have you ever been a member of any International, National, State
or Local Medical Society or Association? If so, please state the name of each such society or
GREETINGS:
association COMMAND the inclusive dates of yourexcuses being laid aside, you and each of you attend before
WE and indicate YOU, that all business and membership.
,
the Honorable
at the
Court
located at
County ofANSWER:
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
42.
Has your membership in any professional association ever been suspended or revoked
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
or has on whose behalf this subpoena was issued your membership? If of please give the details of
the partyany such association ever refused to renew for a maximum penalty so, $50 and all damages sustained as a
result of your failure to comply.
each such suspension, revocation or refusal of renewal including in your answer the name of the
Witness, Honorable
, one of the Justices of the
association, the dateCounty,
of suspension, revocation or refusal of renewal and the reasons therefor and the
Court in
day of
, 20
date, if any, on which your membership was reinstated.
(Attorney must sign above and type name below)
ANSWER:
Attorney(s) for
43.
If you have ever applied for and been denied membership in any professional
association, please state the name of the association, the date of the denial and the reasons therefor.
Office and P.O. Address
ANSWER:
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
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COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
:
44.
Index No.
Calendar No.
:
If you have ever been subjected to disciplinary proceedings bySUBPOENA
JUDICIAL any professional
Plaintiff(s)
-against:
association, please indicate the name of the association, the date of the proceedings, the reasons
therefor and the action taken.
ANSWER:
:
:
Defendant(s)
:
......................................................
45.
Please recite completely the details of your professional work and experience,
THE PEOPLE OF THE STATE OF NEW YORK
including in your answer a description of the nature and scope of your experience, a bibliography of
TO
publications to your credit, a list of committees and boards of which you are or have been a member,
a list of research projects in which you have participated, a description of your area of specialization,
GREETINGS:
an indication of the length of that all business and excuses being specialty practice, each of list of the before
WE COMMAND YOU, time you have been engaged in laid aside, you and and a you attend
,
the Honorable
at the
Court
communities in which you practice orat
located have practiced.
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
ANSWER:
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
46.
Please state subpoena was issued for a on which you have appeared damages sustained as a
the party on whose behalf this the date of each occasionmaximum penalty of $50 and all in court as an
result of your failure to comply.
expert witness and for each such date identify the case in which you testified, identify the party by
Witness, Honorable
, one of the Justices of the
whom
Court in you were called to the witness stand and describe the substance of your testimony.
County,
day of
, 20
ANSWER:
(Attorney must sign above and type name below)
47.
Please state the name and address of each Attorney(s) for or other health facility or
hospital, clinic
institution with which you are or have ever been affiliated other than as a student or house officer and
as to each such institution indicate the nature of your affiliation, the inclusive dates thereof and your
Office and P.O. Address
title or titles.
ANSWER:
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
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COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
:
Plaintiff(s)
48.
Calendar No.
:
JUDICIAL SUBPOENA
-againstHave your privileges at or has your association :
with any hospital, clinic or other health
:
facility every been suspended, revoked or has renewal ever been refused? If so, please state the
:
details of each such suspension, revocation or refusal of renewal, including in your
Defendant(s)
:
......................................................
answer the name and address of the hospital, clinic or other facility, the dates of the suspension,
revocation or refusal for renewal, the reasons therefor and the dates, if any, on which you were
THE PEOPLE OF THE STATE OF NEW YORK
reinstated.
TO
ANSWER:
GREETINGS:
49.
If you have ever applied for and been denied staff privileges at and each of you attend
WE COMMAND YOU, that all business and excuses being laid aside, youany hospital, clinic or before
,
the Honorable
at the
Court
other health facility, please indicate its name and address, the date of the denial and the reasons
located at
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
ortherefor. date, to testify and give evidence as a witness in this action on the part of the
adjourned
ANSWER:
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.
50.
Please state the name and address of each medical school of which you hold or have
Witness, Honorable
, one of the Justices of the
ever held a teaching position, and asof each such school indicate the department to which you are
Court in
County,
day to
, 20
or were assigned, the specific nature and scope of your teaching activities, the inclusive dates of your
appointment and your title or titles.
ANSWER:
51.
(Attorney must sign above and type name below)
Attorney(s) for
Please state the name and address of each person, partnership, corporation,
Office and P.O. Address
governmental unit or agency or other type of organization by which you are employed or have ever
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
been employed in your professional career and indicate the nature and scope of your work, the
American LegalNet, Inc.
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COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
:
Index No.
Calendar No.
:
inclusive dates of your employment and your title or titles. If you JUDICIAL SUBPOENA
have ever been discharged from
Plaintiff(s)
-against:
any such employment, please recite the details of each such discharge, including in your answer the
:
following: name and address of the employer, the date of discharge, the reasons therefor, and the
date, if any, on which you were reinstated.
:
Defendant(s)
:
......................................................
ANSWER:
THE PEOPLE OF THE STATE OF NEW YORK
52.
Please state the name and address of each group practice organization with which you
TO
are or have ever been associated and as to each such organization, indicate the inclusive dates of your
association, the nature and scope of your relationship with it, and the reasons for any termination of
GREETINGS:
your association.
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 ofANSWER:
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
53.
Do you have any insurance agreements which will indemnify you, in whole or in party,
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
against on judgment plaintiff may obtain issued for a maximum If so, state the name damages sustained as a
the party anywhose behalf this subpoena was in the instant action? penalty of $50 and alland address of
result of your failure to comply.
the company or companies issuing such insurance including the policy number and limits of personal
Witness, Honorable
, one of the Justices of the
injury
occurrence mentioned in plaintiff’s Petition. In addition state the
Court in coverage on the date of theday of
County,
, 20
following:
(Attorney must sign above and type name below)
(a)
Are they claims made;
(b)
Occurrence;
(c)
State the limits for each such policy and the policy period covered.
ANSWER:
54.
Attorney(s) for
Office and P.O. Address
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
Please list in chronological order the names and addresses of all persons who have
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COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
:
:
received or made a claim in writing seeking monetary damages:
Plaintiff(s)
ANSWER:
-against-
Index No.
Calendar No.
JUDICIAL SUBPOENA
:
:
:
Defendant(s)
:
......................................................
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.
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
Revised: 5-19-99
Office and P.O. Address
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
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