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Fact Sheet For Social Security Appeals Plaintiff Form. This is a Ohio form and can be use in USDC Southern Federal.
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Tags: Fact Sheet For Social Security Appeals Plaintiff, Ohio Federal, USDC Southern
COURT
COUNTY . .
. . . . . . . . . .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
:
Index No.
:
Plaintiff(s)
Calendar No.
:
JUDICIAL SUBPOENA
-against- THE UNITED STATES :DISTRICT COURT
IN
FOR THE SOUTHERN DISTRICT OF OHIO
:
_____________DIVISION
:
FACT SHEET FOR SOCIAL SECURITY APPEALS: PLAINTIFF
Defendant(s)
:
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (For .each .item, .cite .specific page of record)
.... .... .... ... .....
Case Name: ______________________________________________________________________
THE PEOPLE OF THE STATE OF NEW YORK
1.
2.
Date of application: __________________________________________________________
3.
TO
Type of application: __________________________________________________________
Disability onset date: _________________________________________________________
GREETINGS:
4.
Date of expiration of insured status: _____________________________________________
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
5.
Vocational Factors: __________________________________________________________
located at
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
Date of Birth:give evidence asAge: __________ (At on theof hearing)
__________ a witness in this action time part of the
or adjourned date, to testify and
Education: (last grade completed): ______________________________________________
Your failure work experience: ________________________________________________________
Past 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
Last date worked and job held: _________________________________________________
Court in
County,
day of
, 20
___________________________________________________________________________
6.
(Attorney must sign above and type name below)
Basis of ALJ’s decision _______________________________________________________
(nonsevere impairment, prima facie case, Grid, vocational testimony, etc.)
7.
If claim is based on specific injury, specify injury:
8.
If claim is based on diseases; specify disease: and P.O. Address
Office
9.
During your argument, please refer to specific medicalNo.: relied upon as clinical support
Telephone reports
for disability.
Facsimile No.:
Attorney(s) for
E-Mail Address:
Mobile Tel. No.:
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