COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : KANSAS SOCIAL AND REHABILITATION SERVICES Calendar No. : APPLICATION FOR INFORMATION JUDICIAL SUBPOENA Plaintiff(s) -against- : In Accordance With K.S.A. 39-709b and Kansas Administrative Regulation 30-2-11 : I, ___________________________________, Social Security Number ____/___/_____, : hereby request the Kansas Social and Rehabilitation Services to disclose and provide to the law Defendant(s) : . .firm.of. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . ____________________________________________________________________________, information I previously submitted to SRS or was supplied to me by SRS, or SRS records THE PEOPLE OF THE STATE OF NEW YORK concerning me or my children, as follows: TO ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ GREETINGS: ______________________________________________________________________________ before WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend , the Honorableinformation request is for the following purpose(s): Court at the My 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 ______________________________________________________________________________ I further authorize and consent to the disclosure and copying of these records for the Your failure to comply above-mentioned purposes. 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 IN of your failure to comply. resultCONSIDERATION OF SUCH DISCLOSURE ON THE PART OF THE ABOVE NAMED PERSONS AND/OR INSTITUTIONS, I HEREBY RELEASE THEM FROM ANY AND ALL LIABILITY ARISING THEREFROM AND AGREE TO HOLD THEM HARMLESS FROM Witness, Honorable , one of the Justices of the ANY LIABILITY RESULTING THEREFROM. , 20 Court in County, day of Date ____________________ Signed __________________________________ (Attorney must sign above and type name below) BE IT REMEMBERED, that on this _____ day of ___________________, 20_____, before me personally appeared _____________________________, know to me to be the person Attorney(s) for named in and who executed the foregoing instrument of writing and acknowledges the execution of the same. ______________________________ Office and P.O. Address Notary Public My appointment expires: _________________ Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com