COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Maryland Workers’ CompensationIndex No. Commission Financial Reporting System : Calendar No. Selected Data From Audited Financial Statements Plaintiff(s) Part I - General 1. Name of Company: -against- : JUDICIAL SUBPOENA : (From Audit Report) : 2. Entity Type: 3. Industry Group: : Defendant(s) : Part II. – .Balance .Sheet . . . .Note:.All .numbers .are. to. the .nearest. dollar. Use minus (-) for negative. No $ signs. . . ........ ..... .... .. ....... .. . ... ..... . Previous Year/Month/Day Reporting Year Ended: Current Year/Month/Day 1. Cash & Equivalents and Short-Term Securities THE PEOPLE OF THE STATE OF NEW YORK 2. NetTO Receivables 3. Total Current Assets 4. Total Fixed Assets GREETINGS: 5. Total Assets WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court 6. Current Liabilities located at County of 7. Long-Term Debt 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 8. All Other Liabilities (Total Liabilities minus 6 & 7) 9. Equity (Net Worth or Net Assets) Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to 9 a. Retained Earnings behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a the party on whose result of your failure to comply. 9 b. Net Unrestricted Assets (NFP only) Witness, Honorable Court in County, , one of the Justices of the 10. Market Capitalization (BS Date) (Listed Only) day of , 20 Part III – Income Statement 11. Total Sales or Revenue (Attorney must sign above and type name below) 12. Income (Loss) From Operations & Before Interest and DD&A Attorney(s) for 13. Interest Expense (Show as positive number) 14. Depreciation (DD&A) Office and P.O. Address 15. Income Taxes (Expense [Benefit]) 16. All Other Non-Operating Items Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: 17. Net Income (Loss) American LegalNet, Inc. www.USCourtForms.com 1-4 COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. Maryland Workers’ Compensation Commission : Index No. Financial Reporting System : Calendar No. Selected Data From Audited Financial Statements Part IV – Cash Flow Plaintiff(s) 18. Cash Flow from Operations-against- : JUDICIAL SUBPOENA : 19. Purchase of PPE (Show as positive number) : 20. Cash From Investing : 21. Debt Proceeds Less Pay Downs Defendant(s) : ...................................................... 22. Cash From Financing 23. Net Cash Flow THE PEOPLE OF THE STATE OF NEW YORK Part V – Hospital and Health Care Organizations Only TO 24. Gross Patient Revenue 25. Bad Debt Expense GREETINGS: 26. Allowance for Bad Debts WE COMMAND YOU, 27. Fees Waived For Charity Care that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of Comments and Explanations day of in room , on the , 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 Office and P.O. Address Contact Information Title: Telephone No.: Name: Telephone: Facsimile No.: E-Mail Address: Mobile Tel. No.: Email: American LegalNet, Inc. www.USCourtForms.com 2-4 COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. Maryland Workers’ Compensation Commission : Index No. Financial Reporting System : Calendar No. Selected Data From Audited Financial Statements INSTRUCTIONS : Plaintiff(s) JUDICIAL SUBPOENA General -against: Consistent with the requirements of LE § 9-406(1)(i), the Commission periodically evaluates the financial strength of a self-insured employer (SIE). Information in the audited financial statement submitted annually by : the SIE is one tool used to perform this evaluation. The results of such evaluations are taken into consideration along with other data when determining changes in SIE status, such as, changes in retention and security as well : as continuing program participation. As an assist in the analysis and evaluation process, the Commission has developed several financial models that score financial performance. The results of such modeling are used as Defendant(s) : ... .. ....... ...... ... . ......... .... .. ..... .. indicators. of .financial .strength. and. as. necessary,.drive .the. extent. and direction of further analysis. The financial models are consistent with Altman’s Z score evaluation techniques and ratio analysis similar to that published on the Internet for publicly-held companies and in publications such as RMA’s Annual l Financial Statistics THE PEOPLE OF THE STATE OF NEW YORK Disclosure of Information WhileTO financial information provided by the SIE maybe in the public domain, the results of any analysis by the the Commission are not. Accordingly, the results of the Commission analysis and evaluation may not be disclosed to any other person outside the Commission consistent with LE § 9-1104. The Commission may from time to time aggregate these statistics to determine trends and industry performance. If such information is made GREETINGS: be in aggregate form only, and will not disclose the name of the organizations whose data is public, it will included in the aggregation of any table or array of statistics. WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court Due Date located at County of 30 days after the issuance date of the audited financial statements. A hard copy of the audited This report is due in statements along with the 10-K, if applicable,20 , on the day of , shouldat mailed to the following address no any recessed , be o'clock in the noon, and at later than financialroom or adjourned date, to testify and give evidence as a witness in this action on the part of the 30 days after issuance. Maryland Workers’ Compensation Commission Insurance Division Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to 10 East Baltimore Street the party on whose behalfBaltimore, Maryland 21202 a maximum penalty of $50 and all damages sustained as a this subpoena was issued for result of your failure to comply. Conventions Witness, Honorable , only the Justices of the All dollar amounts should be entered to the nearest dollar. Use a negative signone ofwhen it is shown as negative is the financial statement except for the purchase 20 PPE or capital expenditures should always be Court in County, day of , of reported as a positive. Specific Instructions (Attorney must sign above and type name below) Part I – General Attorney(s) for Item 1 – If the SIE is a subsidiary of a publicly-held company, list the name of the publicly-held company providing the parental guarantee. Item 2 – Select one of the following Entity Types A. Publicly-Held Corporations B. Privately-Held Corporations C. Not-For-Profit Entities D. Government 3-4 Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. Maryland Workers’ Compensation Commission : Index No. Financial Reporting System : Calendar No. Selected Data From Audited Financial Statements Part I – General (continued) Plaintiff(s) : JUDICIAL SUBPOENA -against: Item 3 – Select one of the following Industry Classifications: : 01 - Utilities 02 - Airlines : 03 - Service 04 - Food Defendant(s) : . .05 . .Retail . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..- ..... 06 - Manufacturers and Producers 07 - Auto 08 PEOPLE OF THE STATE OF NEW YORK THE - Energy – Oil 09 - Ground Transpiration 10 TO - Technology 11 - Construction 12 - Dealers 13 - Hospitals and Health Care GREETINGS: 14 - Other Non-Profits 15 - School Systems WE COMMAND YOU, that 16 - Other Government Entities all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court 17 - All Other located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed orPart II – Balancetestify and give evidence as a witness in this action on the part of the adjourned date, to Sheet Year Ended – Please enter the dates and financial data for the latest two accounting years. The data must be taken from the audited financial statements. All data elements should be self-explanatory except for item 10. Market capitalization is the number of common shares outstanding times the per Your price of the company’s subpoena is punishable sheet date. Privately-held and non-profits share marketfailure to comply with this stock as of the balanceas a contempt of court and will make you liable to the party leave this behalfelement blank.was issued for a maximum penalty of $50 and all damages sustained as a should on whose data this subpoena result of your failure to comply. Part III – Income Statement: Self-explanatory , one of the Justices of the Part VIWitness, Honorable – Statement of Cash Flow: Self-explanatory Court in – Hospital County, day of , 20 Part V and Health Care Organizations Only: Self-Explanatory, Item 27 is normally disclosed in the notes to the financial statements Comments and Explanations (Attorney must sign above and type name below) This space can be used to disclose additional information considered necessary for understanding the information provided in this report. Attorney(s) for Contact Information This report should be prepared or reviewed by a member of the organization’s financial staff familiar with financial statements. Please provide the name of the individual and contact information for resolving any issues related to this submission. Inquiries about this report should be directed to: Office and P.O. Address Tom Murphy, CPA, Director Insurance Division (410) 864-5292 email: info@wcc.state.md.us. 4-4 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com