COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : State of New Hampshire Department of Labor : Concord, NH 03301 -against- : Plaintiff(s) QUESTIONNAIRE : Index No. Calendar No. JUDICIAL SUBPOENA Name of Self-Insurer ___________________________________________________________________ : Address ______________________________________________________________________________ : The following information is supplied for Labor Department use only for PAID workers’ Defendant(s) : . .compensation benefits. under. NEW. HAPSHIRE LAW . . . .calendar year _______ or your fiscal year that . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . for . . . . . ended in calendar year ________. Period covered: From ______________ 19______ through _________________19 ___________ THE PEOPLE OF THE STATE OF NEW YORK 1. 281-A:23 Medical , Hospital and Remedial Care $_________________ TO 2. 281-A:25 Vocational Rehabilitation _________________ 3. 281-A:26 Compensation for Death GREETINGS: (a) Dependent Benefits $_______________ WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable (b) Burial Expenses at the _______________ Court located at County of Total (a), & (b) in room , on the day of , 20 at o'clock in the _________________ recessed noon, and at any or adjourned date, to testify and give evidence as a witness in this action on the part of the 4. 281-A:28 Compensation for Total Disability _________________ (Statutory payments only, please exclude supplemental sick leave benefits) Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on 281-A:29 Adjustedsubpoena was issued for a maximum penalty of $50 and all damages sustained as a 5. whose behalf this Total Disability (If any) _________________ result of your failure to comply. 6. 281-A:31 Compensation for Temporary Partial _________________ Disability Witness, Honorable , one of the Justices of the Court in County, day of , 20 7. 281-A:32 Scheduled Permanent Impairment Awards _________________ 8. 281-A:37 Lump Sum Payments _________________ (Attorney must sign above and type name below) Total (1 through 8) $_________________ Attorney(s) for (signed) _____________________________________________ _____________________________________________ Title Office and P.O. Address ____________________________________________ Date Telephone No.: Facsimile No.: Please complete and return to the New Hampshire Labor Department, 95 E-Mail Address: Pleasant Street, State Office Park South, Concord, NH 03301 no later than Mobile Tel. No.: March 31, ____________. American LegalNet, Inc. www.USCourtForms.com