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Petition For Forfeiture Form. This is a Maine form and can be use in Workers Compensation.
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Tags: Petition For Forfeiture, Maine Workers Compensation,
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Index No.
Calendar No.
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JUDICIAL SUBPOENA
Plaintiff(s)
STATE OF MAINE
-against- Workers Compensation Board
:
Abuse Investigation Unit
:
State House Station #27, Augusta, Maine 04333-0027
PETITION FOR FORFEITURE
39-A M.R.S.A. 324 :
Defendant(s)
:
. . . . . .PETITIONER-EMPLOYEE . . . . . . . . . . . . . . . . . . . . . RESPONDENT-EMPLOYER
........................
...
Name:
Name:
Address:
Address:
Social Security Number:
THE PEOPLE OF THE STATE OF NEW YORK
RESPONDENT-INSURER
TO
I,
, of
, petition the
Workers Compensation Board for a forfeiture against the respondent, and as a basis of my claim allege that:
GREETINGS:
1. On the
day of
, 20
, while working as a
in the employ of that all business and excuses being laid aside, you received aof you attend before
at
, I and each personal injury
WE COMMAND YOU,
arising out of and in the course of my employment.
,
the Honorable
at the
Court
located at
County ofOn the
2.
day of
, 20 , the Workers Compensation Board:
in room
,
day of
, 20
, at
o'clock in the
noon, and at any recessed
(Check One) on the
or adjourned date, to testify and give evidence as a witness in this action on the part of the
9
A. issued a decision or order granting my petition
filed in regard to
the above-described injury. The Board ordered payment of compensation in the amount of
$
for the period of
, 20
to
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
, 20 ; or
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
9
result of your failure toB. approved an agreement for the payment of compensation in the amount of $
comply.
for the period of
, 20
to
, 20 .
Witness, Honorable
, one of the Justices of the
Court in The respondent has failed daycomply with the20
County,
, Board order or decision or approved agreement by
3.
to of
not paying the compensation ordered or agreed to be paid until
, 20 .
WHEREFORE, the petitioner asks that the Board award the petitioner such forfeiture as the petitioner may
(Attorney must sign above and type name below)
be entitled to pursuant to 39-A M.R.S.A. 324(2).
Dated at
Name of Worker Advocate
this
day of
Attorney(s) for
20
.
Signature of Petitioner-Employee
Office and P.O. Address
Address of Worker Advocate
Rev. (1/98)
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
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