Social Security Release Form
Social Security Release Form. This is a Kentucky form and can be use in Workers Comp.
Tags: Social Security Release Form, 115, Kentucky Workers Comp,
COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Form 115 Adopted 1/ 1/97 Plaintiff(s) -against- Calendar No. : JUDICIAL SUBPOENA : KENTUCKY : DEPARTMENT OF WORKERS CLAIMS SOCIAL SECURITY RELEASE FORM : Defendant(s) : ...................................................... I, ___________________________, having filed an Application for Resolution of Occupational Disease or Hearing Loss Claim for workers compensation THE PEOPLE OF THE STATE OF NEW YORK benefits, do hereby authorize the Social Security Administration to release or TO disclose to the Department of Workers Claims any information in their possession concerning my benefit or wage earnings. GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court Signed at ______________________, Kentucky, this _______ day of located at County of in______________________, 20____., 20 room , on the day of , 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 Plaintiff's Signature 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, day of ________________________ Witness Signature ______________________________ , one of the Justices of the Social Security Number , 20 (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com