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Employment Information Affidavit Form. This is a North Carolina form and can be use in District 24 Local County.
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Tags: Employment Information Affidavit, A And B, North Carolina Local County, District 24
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
:
NORTH CAROLINA
Index No.
Calendar No.
IN THE GENERAL COURT OF JUSTICE
DISTRICT COURT DIVISION
:
JUDICIAL SUBPOENA
Plaintiff(s)
* -CVD- *
* COUNTY
-against-
:
:
*,
)
:
)
Plaintiff,
)
Defendant(s)
:
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .) . . . . . . . . . . . . . . . . . . . . . .
v.
)
)
*,
)
THE PEOPLE OF THE STATE OF NEW YORK
)
Defendant.
)
TO
______________________________)
AFFIDAVIT
_________________________________ (personnel officer), being first duly sworn,
GREETINGS:
deposes and says:
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
That he/she is an employee of ____________________________________________
located at
County of
located in ____________________________________________________________; that
in in the
, on the
, said , at
o'clock record
noon, hereto
*,* room above entitled action,dayan employee of20 company; that the in the attached and at any recessed
is of
adjourned date, to testify and give evidence as a witness in this action on the part of the
ofor*’s earnings, deductions, company benefits and length of employment is true and correct to
the best of affiant’s information and belief.
This thefailure to comply with this subpoena is punishable as a _______. of court and will make you liable to
Your _______ day of __________________________, contempt
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,
day of
, one of the Justices
_______________________________of the
Affiant (personnel officer)
, 20
_______________________________
Title: (Attorney must sign above and type name below)
Subscribed and sworn to before me this the ______ day of ____________________,
Attorney(s) for
________________.
___________________________________
Notary Public
Office and P.O. Address
My commission expires: ___________________
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
Form “A”
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COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
:
Calendar No.
:
JUDICIAL SUBPOENA
EARNINGS INFORMATION
1.
Plaintiff(s)
Earnings last calendar year, including bonus, if any:
-against-
a)
b)
gross:
net:
:
$________________
$________________
:
:
Present rate of pay: $__________________ per _____________________.
If paid on production or commission, what is present average gross pay?
Defendant(s)
:
. . . . . . . . . . . . . . . . . . . . . . . . . . ____________________.. . . . . .
$_______________Per . . . . . . . . . . . . . . . . . . . . . .
2.
3.
How often is employee paid? ____________________________________
THE PEOPLE OF THE STATE OF NEW YORK
4.
TO
Number of hours working per day: _______________________________
5.
Number of days working per week: _______________________________
6.
Deductions from gross pay per pay period:
GREETINGS:
a)
State taxes:
$ ______________________
b) WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
Federal taxes:
$ ______________________
,
the Honorable FICA:
at the
Court
c)
$ ______________________
located at $ ______________________
County of
d)
Medical Insurance *:
in room How muchon the
, of medical day of
, 20
, at
noon,
*
insurance premium is allocated foro'clock in the children? and at any recessed
coverage of
or adjourned date, to testify and giveper _________________________. the part of the
$ ____________________ evidence as a witness in this action on
7.
Number of exemptions claimed: _____________________________________
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
8.the party onemployee lastthis subpoena was issued for a maximum penalty of $50 and all damages sustained as a
Date whose behalf paid: _________________________________________
result of your failure to periods, if any, are employee’s earnings retained by employer?
How many pay comply.
______________________________________________________________
Witness, Honorable
, one of the Justices of the
9.Court Earnings this calendar year through date employee last paid, including bonus, if any:
in
County,
day of
, 20
a)
b)
gross:
net:
$ _____________________
$ _____________________
(Attorney must sign above and type name below)
10.
Is employee paid a bonus? ________________________
If “yes” explain:
a)
How computed: _________________________________________
Attorney(s) for
b)
When paid: _____________________________________________
c)
Amount paid last calendar year: ____________________________
d)
Amount paid this calendar year: ____________________________
Office and P.O. Address
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
Form “B”
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COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
11.
:
Index No.
Calendar No.
What pay increase, if any, has employee received in past twelve (12) months?
:
JUDICIAL
Plaintiff(s)
Increase amount(s): _________________________________________ SUBPOENA
-against-
:
Date(s) received: __________________________________________
:
12.
Nature of employment: ______________________________________
:
13.
Date of hire: _______________________________________________
Defendant(s)
:
......................................................
14.
Amount paid by employer on employee’s behalf for:
a)
b)
c)
d)
e)
Medical insurance
Disability insurance:
Dues:
Retirement:
Reimbursed Expenses:
$ ______________per ______________.
$ ______________per ______________.
$ ______________per ______________.
$ ______________per ______________.
$ ______________per ______________.
THE PEOPLE OF THE STATE OF NEW YORK
TO
15.
Amount
GREETINGS: of overtime employee worked in the past twelve (12) months.
________________________________________________________________
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable of overtime that was available to employee in the Court
at the
16.
Amount
past twelve (12) months.
located at
County of
__________________________________________________________________
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
17.
Please describe changes employee should expect, if any, within three months in job
description, compensation and/or working hours:
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
, one of the Justices
__________________________________________________________________ of the
18.
Court If not previously described herein, please describe changes, if any, employee has had
in
County,
day of
, 20
within past three months in job description, compensation and/or working hours:
__________________________________________________________________
__________________________________________________________________ below)
(Attorney must sign above and type name
__________________________________________________________________
__________________________________________________________________
Attorney(s) for
Office and P.O. Address
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
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