COUNTY . . . . . . . . . . . .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : Index No. : Calendar No. : JUDICIAL SUBPOENA Better Workers’ Compensation Built with you in mind. Plaintiff(s) Instructions: -against•This form must be submitted prior to payment by BWC to avoid a possible overpayment to the employee. •Employer and employee must sign and date this agreement. •Mail or fax this completed form to your local BWC service office. : : : Defendant(s) : ...................................................... Employee name Wage Agreement Date of injury Employer name Claim number Telephone number 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 employer has paid or agrees to pay an advancement of wages to the above employee until the payment of , the Honorable at the Court temporary total compensation begins. Advancement of wages begin on _______________________ to located at County of in room , on at day $ , per , at o'clock $ __________ . at any recessed noon, and ______________________the a rate of of __________20 week for a total ofin the or adjourned date, to testify and give evidence as a witness in this action on the part of the By signing this agreement, the employer and employee have entered into a Wage Agreement to reimburse the Your the extent of any compensation is punishable as a contempt the same period in which wages employer at least tofailure to comply with this subpoenapaid to the employee over of court and will make you liable to the party onadvancements made. were paid or the 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 This agreement shall grant BWC the authority to send warrants for Temporary Total Compensation to the Court in County, day of , 20 employee in care of the employer for no more than the first 12 weeks of compensation closely following the date of injury. BWC may pay a wage agreement beyond 12 weeks involving special circumstances. (Attorney must sign above and type name below) Attorney(s) for Employee signature Date Employer signature and title Date Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: BWC-1123 (6/13/2001) C-18 American LegalNet, Inc. www.USCourtForms.com