COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. OMB NO. 1293-0002 (EXP 03/31/2007) VETS/USERRA/VP Form 1010 (REV 2/99) : Calendar No. : JUDICIAL SUBPOENA Plaintiff(s) ELIGIBILITY DATA FORM: For claims under the Uniformed Services Employment and Reemployment Rights Act (USERRA) and/or claims under the Veterans’ Preference (VP) provisions of the Veterans Employment Opportunities Act of 1998 -against: U.S. Department of Labor, Veterans’ Employment and Training Service : PLEASE TYPE OR PRINT Section I: Claimant Information : 1. Name: __________________________________________________________________________________________________________________ Last Name First Name M.I. Defendant(s) : ...................................................... 2. Address: _________________________________________________________________________________________________________________ Street City State ZIP 3. Social Security No: _________________________ 4. Home Phone: _________________________ 5. Work Phone: _______________________ THE PEOPLE OF THE STATE OF NEW YORK TO Section II: Uniformed Service Information 6. Serve(d) In: ? Army ? Navy ? Marine Corps ? Air Force ? Coast Guard ? National Guard ? Reserve ? Public Health Service ? Other (Explain in “Comments”) ? None (Retaliation Claim – Explain in “Comments”) GREETINGS: 7. If Reserve/National Guard: Name ofWE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Unit: _______________________________________________________________________________ , the Honorable at the Court (b) Unit Address: _______________________________________________________________________________ located at County of (c) room in Unit Phone: _______________________________ , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify (a) From: ________________ witness in this action on the part of the and give evidence as a To: _______________ Dates of Service (If applicable): (a) 8. OR (b) Date of Examination/Rejection for Service: ________________ 9. Type of Discharge or Separation: ? Honorable Conditions ? Entry Level ? Uncharacterized ? Medical ? OtherYour failureConditions ? Other (Explain in “Comments”) ? Not Applicable contempt than Honorable to comply with this subpoena is punishable as a 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 Section III: Employer Information 10. Employer or Prospective Employer’s Name: _______________________________________________________________________ (Attorney must sign above and type name below) 11. Address: __________________________________________________________________________________________________________ Street City County State ZIP 12. Principal Employer Contact (PEC): (a) PEC Name/Title: ___________________________________________ (b) PEC Phone: __________________________________________ 13. Employment Dates (If applicable): To: ____________________ From: ____________________ Attorney(s) for 14. Since beginning work with this employer, has your cumulative uniformed service exceeded 5 years? ? Yes ? No If YES, explain in Comments box at end of this claim form. Office and P.O. Address 15. Name of Union(s) That Represent You: ______________________________________________________ Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY . . . . . . . . . . . .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : Section IV: Claim Information Index No. : Calendar No. : JUDICIAL SUBPOENA If Claim Concerns Veterans’ Preference in Federal Employment 16. Preference Issue (Check One): ? Hiring ? Reduction-in-Force (RIF) Plaintiff(s) -againstIf Claim Concerns Employment Discrimination under USERRA : 17. Employment Discrimination Issue(s): ? Hiring ? Reemployment ? Promotion ? Termination ? Benefits of Employment : If Claim Concerns Hiring, Promotion, RIF or Termination : 18. Title of Position Held or Applied For: _____________________________________________________________ Defendant(s) : ...................................................... 19. Pay Rate: __________________________ 20. Date of Application Employment/Promotion: ________________________ 20a. Vacancy Announcement No.: ______________________________________________________________________ 20b. Date Vacancy Opened: __________________________ 20c. Date Vacancy Closed: _________________________ THE PEOPLE OF THE STATE OF NEW YORK If Claim Concerns Reemployment Following Service 21. TO Prior Notice of Service Provided to Employer? Was 22. (a) Who Provided Notice of Service to Employer? (b) Was the Notice of Service: ? Yes ? No (If “No,” Explain in Comments) ? Self ? Other (name): _______________________________________ ? Written ? Oral ? Both GREETINGS: (c) Date Notice of Service was given to Employer: _______________________ 23. Name/Title of Person to Whom NoticeYOU, that all business and excuses being laid aside, you WE COMMAND of Service was Provided: _________________________________________ 24. 25. 26. and each of you attend before , the Honorable at the to Work: ______________________ Court Date Applied for Reemployment: ______________________ OR Date Returned located at County of Reemployment Application Made To: Name: _________________________________ Title: _____________________________ in room , on the day of , 20 , at o'clock in the noon, and at any recessed Reemployed or Reinstated? ? Yes and ______________________ ? No or adjourned date, to testify (date):give evidence as a witness in this action on the part of the (a) If YES, what position? ____________________________________ at what pay rate? ________________________ (b) If NO, Date denied: ___________________ Reason given: ______________________________________________ Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to (c) Who denied (name): ____________________________________ the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a PUNISHMENTyour UNLAWFUL STATEMENTS result of FOR failure to comply. The information provided in this complaint will be utilized by the U.S. Department of Labor, Veterans’ Employment and Training Service (VETS) to initiate an investigation of alleged violations of the Uniformed Service Employment and Reemployment Rights Act (USERRA) and/or the Veterans’ Preference (VP) provisions of the Veterans Employment Opportunities Act of 1998 (VEOA). Potential claimants should keep in one of the Justices of the Witness, Honorable , mind that it is unlawful to “knowingly and willfully” make any “materially false, fictitious, or fraudulent statements or representation” to a federal agency. Violations can be punished under Section 2 of Court in County, day of , 20 the False Statements Accountability Act of 1996 by a fine and/or imprisonment of not more than 5 years. 18 U.S.C. § 1001. I certify that the above information is true and correct to the best of my knowledge and belief. I authorize the U.S. Department of Labor to contact my employer or any other person for information concerning this claim. Pursuant to 5 U.S.C., Section 552(b) of the Privacy Act, I consent to the release of the above information and any records necessary for the investigation and prosecution of my claim. (Attorney must sign above and type name below) SIGNATURE: ___________________________________________________________ DATE: _________________________________ Persons are not required to response to the collection of information unless it displays a currently valid OMB control number. Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any Attorney(s) for other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Veterans’ Employment and Training Service, Room-S1316, 200 Constitution Avenue, N.W., Washington, DC 20210. PRIVACY ACT STATEMENT The primary use of this information is by staff of the Veterans’ Employment and Training Service in investigating cases under USERRA or laws/regulations relating to veterans’ preference in Federal employment. Disclosure of this information may be made to: a Federal, state or local agency for appropriate Office and P.O. the information on this form, including reasons; in connection with litigation; and to an individual or contractor performing a Federal function. FurnishingAddress your Social Security Number, is voluntary. However, failure to provide this information may jeopardize the Department of Labor’s ability to provide assistance on your claim. Continue in Comments box &/or use additional sheet(s) to explain items if needed – Sign and date form (above) Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: OMB NO. 1293-0002 (EXP 03/31/2007) VETS/USERRA/VP Form 1010 (REV 2/99) – Page 2 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. Explain your claim in detail – List all remedies you seek Use additional sheet(s) if needed – Initial & date:each page at bottom Calendar No. : JUDICIAL SUBPOENA Plaintiff(s) Comments: _____________________________________________________________________________________________________ ________________________________________________________________________________________________________________ -against: ________________________________________________________________________________________________________________ : ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ : ________________________________________________________________________________________________________________ Defendant(s) ________________________________________________________________________________________________________________ : ...................................................... ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ THE PEOPLE OF THE STATE OF NEW YORK ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ TO ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ GREETINGS: ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ 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 ________________________________________________________________________________________________________________ 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 ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ 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 ________________________________________________________________________________________________________________ Court in County, day of , 20 ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ (Attorney must sign above and type name below) ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ Attorney(s) for ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ Office and P.O. Address INITIALS: ____________ DATE: ____________ Telephone No.: Facsimile No.: E-Mail Address: OMB NO. 1293-0002 (EXP 03/31/2007) VETS/USERRA/VP Form 1010 (REV 2/99) – Page 3 Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com ,