COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. Nebraska Workers’ Compensation Court : Index No. Record Request Form Calendar No. : OFFICE USE ONLY Any request for public records must be written and addressed to Public Records, Nebraska : Workers’ Compensation Court, P.O. Box 98908, Lincoln, NE 68509-8908, or JUDICIAL SUBPOENA Plaintiff(s) faxed to 402-471-2700, or e-mailed to newcc@wcc.state.ne.us. This form shall be used : to request records regarding injuries-againstto an individual employee. Ample information should be provided, including: name of the employee and any previous names, social security number, date(s) of injury, date of birth, and a detailed description of the information being requested. Failure to provide this information could : result in a delay of response and/or additional costs. : Unless specifically requested, responses will be limited to first and subsequent reports filed within the last five (5) years. Such requests will be fulfilled within four (4) business days of receipt of this form. There will be no charge for fulfilling these requests if Defendant(s) sufficient information is provided to promptly identify the records. : ...................................................... Requests for records other than first and subsequent reports filed within the last five (5) years may be subject to a charge. These requests may take longer than four (4) business days due to the significant difficulty or extensiveness of the request. Such requests will be fulfilled at the earliest practicable date, and a response will exceed ten (10) business days only rarely. THE PEOPLE OF THE STATE OF NEW YORK If fees are charged, they will be based on the actual cost of conducting the search and providing the copies. It is currently the policy of the court to charge fees if retrieval and copying costs exceed $20.00. This is subject to change at the discretion of the court. If fees are charged, an invoice will be mailed with the response. If retrieval and copying costs are estimated to exceed $50.00, the court may TO require the requester to furnish a deposit prior to fulfilling the request. The requester will be notified in advance of fulfilling the request if the charge is estimated to exceed $50.00. Record Search Information: GREETINGS: Name of Injured Employee (include previous names): WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of Social Security Number: 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 Date(s) of Injury: Date of Birth: Please provide a Your failure to comply with this subpoena requested: detailed description of the information being 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 Requester Information: OFFICE USE ONLY Name: (Attorney must sign above and type name below) Company: Address: City: Attorney(s) for State: Zip: Telephone: FAX: Office and P.O. Address E-mail: q I agree to pay charges in excess of $20.00, but not to exceed $50.00. I understand I will be notified in advance of any charge estimated to exceed $50.00. (Rev. 11/2002) Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com