COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : : Plaintiff(s) -against- Calendar No. JUDICIAL SUBPOENA : : : Defendant(s) : ...................................................... DR-4 IN THE COMMON PLEAS COURT OF SHELBY COUNTY, OHIO DOMESTIC RELATIONS DIVISION THE PEOPLE OF THE STATE OF NEW YORK TO Name:________________________ Address:______________________ ______________________________ SS#: GREETINGS: DOB: * * * WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before PLAINTIFF/OBLIGOR(EE) * CASE NO._____________________ , the Honorable at the Court located at County of VS. * JUDGE________________________ 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 Name:________________________ HEALTH INSURANCE Address:______________________ INVESTIGATIVE AFFIDAVIT ______________________________ * SS#: Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to DOB: * the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a DEFENDANT/OBLIGEE(OR) * result of your failure to comply. * * * * * * * * * * * * * Witness, Honorable , one of the Justices of the Court in INSTRUCTIONS: BY COURTof County, day RULE OF THE SHELBY COUNTY COURT OF COMMON PLEAS, , 20 DIVISION OF DOMESTIC RELATIONS AND JUVENILE BRANCH, YOU ARE TO DISCLOSE ALL SUCH INFORMATION THAT IS REQUIRED. (Attorney must sign above and type name below) CHILDREN SUBJECT TO CHILD SUPPORT ORDER: (Form to be used only when minor children involved.) Attorney(s) for Name_______________________________ DOB _______________________________ SS#_________________________________ Name________________________________ DOB_________________________________ SS#__________________________________ Office and P.O. Address Name_______________________________ DOB _______________________________ SS#_________________________________ Name________________________________ DOB_________________________________ Telephone No.: SS#__________________________________ Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Calendar No. ENTER THE FOLLOWING INFORMATION ABOUT THE PLAINTIFF/PETITIONER: : JUDICIAL SUBPOENA Plaintiff(s) SS#__________________________________ Name_______________________________ Address_____________________________ Work Phone (___)_____________________ -against: ____________________________________ Home Phone (___)______________________ : Employer________________________________________________________________________ Address__________________________________________________________________________ : Phone (___)__________________________ Defendant(s) : . . . . . . . . DO YOU.HAVE .FAMILY HEALTH .INSURANCE .AVAILABLE EITHER THROUGH YOUR EMPLOYER ....... ..... ............... .......... ..... OR ANOTHER GROUP OR ORGANIZATION? ____ Yes ____ No Name of Insurer (not Medicaid) _____________________________________________________ Address THE STATE OF NEW YORK THE PEOPLE OF _________________________________________________________________________ Phone (___)___________________________ Participant Card Available? ____ Yes ____ No TO Prescription Card Available? ____ Yes ____ No Monthly Premium of Individual Plan (Employee Share) $ ________________ Monthly Premium of Family Plan (Employee Share) $ ________________ GREETINGS: ENTER THE FOLLOWING INFORMATION ABOUT THE DEFENDANT/ PETITIONER/ RESPONDENT: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at Court Name_______________________________ the SS#__________________________________ located at County ofAddress_____________________________ Work Phone (___)_____________________ in room ____________________________________ 20 Home Phone (___)______________________ recessed , on the day of , , at o'clock in the noon, and at any or adjourned date, to testify and give evidence as a witness in this action on the part of the Employer________________________________________________________________________ Address__________________________________________________________________________ Phone (___)__________________________ Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party DOwhoseHAVE FAMILY HEALTH INSURANCE AVAILABLE EITHER THROUGH YOUR sustained as a on YOU behalf this subpoena was issued for a maximum penalty of $50 and all damages EMPLOYER OR failure to comply. result of your ANOTHER GROUP OR ORGANIZATION? ____ Yes ____ No Name of Insurer (not Medicaid) _____________________________________________________ Witness, Honorable , one of the Justices of the Address _________________________________________________________________________ Court in Phone (___)___________________________ , 20 County, day of Participant Card Available? ____ Yes ____ No Prescription Card Available? ____ Yes ____ No (Attorney must sign above and type name below) Monthly Premium of Individual Plan (Employee Share) $ ________________ Monthly Premium of Family Plan (Employee Share) $ ________________ SIGNATURES: Attorney(s) for ____________________________________ Plaintiff/Petitioner _____________________________________ Defendant/Respondent ____________________________________ Notary Public Office and P.O. Address _____________________________________ Notary Public Sworn to and subscribed by the Affiant before me this _____ day of ___________, 20_____. Sworn to and subscribed by the Affiant Telephone No.: _____ day of ____________, before me this Facsimile No.: 20_____. E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com