COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : SUPERIOR COURT , ss. -against- Docket No. Index No. Calendar No. STATE OF MAINE: JUDICIAL SUBPOENA Plaintiff(s) DISTRICT COURT ______ :Location Docket No. ______ : Plaintiff : Defendant(s) : . . . . . . . . .v.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . STATEMENT CONCERNING . PUBLIC ASSISTANCE Defendant THE PEOPLE OF THE STATE OF NEW YORK I TO make the following statements. (Check one statement in each section that applies.) 1. The child(ren) of the parties in this action A. Have never received TANF or Medicaid. Neither party intends to file an application GREETINGS: for TANFor Medicaid for the child(ren). WE COMMAND YOU, that all business and excusesMedicaid. aside, you and each of you attend before B. Have received or are now receiving TANF or being laid , the Honorable at the Court at County of C. A party intends to located application for TANF or Medicaid for the child(ren). file an in room , on the day of , 20 , at o'clock in the noon, and at any recessed If B or C is checked, you must send a as a of the in this action motion to of or adjourned date, to testify and give evidence copywitness complaint or on the part thethe Department of Human Services, Support Enforcement Division, Central Office Supervisor, State House Station 11, Augusta, ME 04333-0011. 2. Yourthe parties in this actionsubpoena is punishable as a contempt of court and will make you liable to Of failure to comply with this the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a A. (Plaintiff) (Defendant) is a support enforcement client of the Department of Human result of your failure to comply. Services or has requested the assistance of the Department in establishing, reviewing, modifying, or enforcing a child support order concerning the child(ren). Witness, Honorable , one of the Justices of the Court in B. Neither party has contacted the Department of Human Services for the establishment, County, day of , 20 review, modification, or enforcement of a child support order concerning the child(ren). 3. The Department of Human Services (Attorney must sign above and type name below) A. Has not issued a child support order concerning the child(ren). B. Has issued a child support order concerning the child(ren). Attorney(s) for If B is checked, you must attach a copy of the order. Office and P.O. Address Date: Signature of (Plaintiff) (Defendant) CV-041, Rev. 10/01 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com