COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Plaintiff(s) -against- Calendar No. : JUDICIAL SUBPOENA Page 2 : RELEASE AND SETTLEMENT OF CLAIM COMPUTATION : : 1. Full Amount of Settlement (See Amount on Page 1) Defendant(s) : . . . . . . . . 2.. . . . . . . . . and. Costs.of .Action . . any). . . . . . . . . . . . . . . . . . Expenses . . . . . . . . . . . (If . . . $ $ 3. Expenses and Costs of Action as Percentage of Amount Of Settlement (Divide Amount in Line 2 By Amount in Line 1) % THE PEOPLE OF THE STATE OF NEW YORK EMPLOYER/CARRIER TO 4. Lien $__________ GREETINGS: 5. Less: Pro Rata Share of Expenses and Costs of Action EMPLOYEE/CLAIMANT 7. Employee/Claimant’s Share $ (subtract line 4 from line 1) 8. Less: Pro Rata Share of Expenses and Costs of Action (Percent in Line 3) of and excuses being laid aside, you and 7 $ at the Amount in LineCourt (Percent in Line YOU, WE COMMAND 3) of that all business each of you attend before Amount in Line 4 $__________ , the Honorable located at County of6. Net Amount Owed $ 9. Net Amount Due $ 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 PROOF Your failure to–comply with this subpoena is punishable as a contempt of court and will make you liable to Line 5 Pro Rata Share-Employer/Carrier $_____________ the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a Line 6 – Net Amount Owed-Employer/Carrier _____________ result of your failure to comply. Line 8 – Pro Rata Share-Employee/Claimant Witness, Honorable Line 9 – Net Amount Due-Employee/Claimant Court in County, day of , 20 Full Amount of Settlement _____________ , one of the Justices of the _____________ $ (Attorney must sign above and type name below) Attorney(s) for WC-3PR-1 (7-81) Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Plaintiff(s) -against- Calendar No. : JUDICIAL SUBPOENA : Page 1 RELEASE AND SETTLEMENT OF CLAIM : For the Sole Consideration of _____________________________________Dollars ($ ), : lawful money of the United States to me in hand paid by _________________________________ ___________________the receipt of which is hereby acknowledged, I _____________________ Defendant(s) ________________residing at _____________________________________________________ : . . . . . . . . do . . . . . .release,. acquit, and .forever. discharge .the said .________________________________ . . hereby . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ______________________________________________________________________________ from any and all actions, causes of action, claims and demands, damages, costs, loss of services, expenses, and compensation on account of or in any way growing out of any and all known and unknown personal injuries and THE PEOPLE OF THE STATE OFthe property damage resulting or to result from the accident that NEW YORK occurred on or about ____________ day of _____________, by reason of ______________________________________________________________________________ ______________________________________________________________________________ TO and do hereby for myself, my heirs, executor, and adminis trator, successors and assigns covenant with the said ___________________________________________________________________ ______________________________________________________________________________ to indemnify and save harmless from all claims and demands, costs, loss of services, expenses, GREETINGS: and compensation on account of or in any way growing out of said accident or its result both to person and property, provided however that there shall be deducted from the above sum, pursuant to RSA 281-A:13, YOU, that all business and excuses being laid and the costs each of you WE COMMAND an amount of money equivalent to compensation aside, you andof medical, attend before hospital or other remedial care already paid or agreed or awarded to be paid by the employer or the Honorable at the Court employer’s Insurance carrier _______________________________________________________ located at County of______________________________________________________________________________ amended, said amount being that in Lineo'clock in the this document, at any recessed 4 of Page 2 of in room under RSAon the , 281-A:13, as day of , 20 , at noon, and __________________________________ Dollars ($ ), or adjourned date, to testify and give evidence as a witness in this action on less partemployer’s or the the the of the employer’s insurance carrier’s, pro rata share of expenses and costs of action, if any, as determined under RSA 281-A:13, IV, and provided further that such net amount, being that in Line 6 of said Page 2, ________________________________________________________________ ____________ Dollars ($ ), be paid to the employer or the carrier in satisfaction of one or the other’s lien. It is expressly understood and agreed contempt of court of the said Your failure to comply with this subpoena is punishable as a that the acceptance and will make you liable to amount of behalf this subpoena was issued for maximum),penalty of $50 and satisfaction is in full accord and all damages sustained as a the party on whose ___________________________ Dollarsa($ of my claim in this matter. result of your failure to comply. In Witness Whereof, I have set my hand and seal this _________day of _____________,_______ Witness, Honorable Court in , one of the Justices of the _______________________________________ Name______________________________ (LS) County, , 20 (Witness) day of _______________________________________ Address ________________________________ (Address) (Attorney must sign above and type name below) On this ____________ day of _____________, _______, before me personally appeared ______________________________________________________________________________ Attorney(s) for to be known to be the person described herein, and who executed the foregoing instrument, and he/she acknowledged that he/she voluntarily executed the same. ___________________________________ Notary Public Office and P.O. Address Approval of the Commissioner of Labor granted on this _________day of ____________, ______ Pursuant to par. III, RSA 281-A:13. Telephone No.: ___________________________________ Facsimile No.: Commissioner of Labor E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com ,