COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. STATE OF MICHIGAN HEALTH INSURANCE Case Number : Calendar No. TUSCOLA COUNTY INFORMATION SHEET ______________________ 54TH JUDICIAL CIRCUIT : JUDICIAL SUBPOENA Plaintiff(s) FAMILY DIVISION COMPLETE, SIGN & RETURN TO THE FRIEND OF: THE COURT WITHIN 21 DAYS -against449 GREEN STREET, CARO, MI 48723 Phone: (989) 673-4848 Fax: (989) 673-4898 Email: foc@tuscolacounty.org Website: :www.tuscolacounty.org : Name: ________________________________________________ Defendant(s) : . . Address: ....................................... Current . . . . . . . . . . . . ._________________________________________________ Street City Zip Phone Number _____________________________ Area STATE THE PEOPLE OF THECode OF NEW YORK Soc. Sec. Number ___________________ Birth date _______________ TO Employer Name & Address _________________________________________________ Phone Number _____________________________________ GREETINGS: YES NO ______ _______ WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court ______ _______ Is located at health insurance available through your employer? County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed ______ adjourned date,_______ and give evidence asdowitness in this action on the part of the yourself? If no, a you have private health insurance for or to testify Do you maintain health insurance through your spouse's employer? 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 Please indicate the typesto comply. result of your failure of coverage your insurance provides. _____ MedicalWitness, Honorable _____ Dental Court in County, _____ Hospitalization day of _____ Optical the Justices of the , one of _____ Prescription drugs , 20 List names of all children for whom you maintain insurance coverage: _________________________________________________________________________________ (Attorney must sign above and type name below) Name Date of Birth Soc Sec. No. _________________________________________________________________________________ Attorney(s) for Name Date of Birth Soc Sec. No _________________________________________________________________________________ Name Date of Birth Soc Sec. No Office and P.O. Address (Use back of form if necessary) Attach a photocopy (front & back) of any insurance No.: cards you possess. ID Telephone Date _________________ Facsimile No.: _________________________________ Address: E-Mail Your signature Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com