COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : State of Oregon Department of Consumer and Business Services Workers’ Compensation Division Index No. IRREVOCABLE STANDBY LETTER OF CREDIT : Calendar No. Irrevocable Standby Letter of Credit number: : Issuing bank name/address: JUDICIAL SUBPOENA Plaintiff(s) Effective date: : -againstDate and place of issue: Date: Place: Expiry date and place for presentation of documents: Expiry date: : Place for presentation: : Applicant (self-insured employer) name/address: Beneficiary: Defendant(s)State of Oregon acting by and through, the : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Oregon .Department of Consumer and Business Services ..... . 350 Winter Street NE PO Box 14480 Salem OR 97309-0405 THE PEOPLE OF THE Confirming bank name/address:STATE OF NEW YORK Reference number: Amount: U.S. $ (spell out amount in U.S. dollars) TO (hereinafter referred to as “Issuer”) hereby issues our irrevocable standby letter of [Insert bank name] GREETINGS: credit (hereinafter referred to as “letter of credit”) in favor of the Oregon Department of Consumer and Business Services, on behalf of (hereinafter referred to as the “self-insured employer”) WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before (applicant) , at the Court . located at County is available with of The credit (issuing or confirming bank located in the State of Oregon) 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 the amount of U.S. in the Honorable dollars: by presentation of the beneficiary’s draft drawn at sight on the issuing bank or confirming bank, payable within three business days, when accompanied by one of the four following statements, signed by the director of the Oregon Department of Consumer and Business Services or the administrator of the Oregon Department of Consumer and Business Services, Workers’ Compensation Division, or their designated authorized representative: Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to That the self-insured employer has defaulted in issued for maximum penalty of $50 or obligations, or in sustained the party on whose behalf this subpoena was payment of itsaworkers’ compensation liabilities and all damages payments as a due the failure to comply. result of yourdirector of the Oregon Department of Consumer and Business Services; OR That the self-insured employer has filed for bankruptcy; OR Witness, Honorable Court , one of the Justices of the That the self-insured employer has failed to renew the letter of credit or substitute acceptable security for workers’ in County, day of 20 compensation liabilities and obligations by fifteen (15) days ,before the expiry date of the letter of credit; OR That the beneficiary has determined that the existing security is deemed to be inadequate; that additional or replacement security must be provided by the self-insured employer and that neither has been provided, notwithstanding written notice to the (Attorney must sign above and type name below) self-insured employer. This letter of credit is payable at: (branch of bank, name and address) . Attorney(s) for must be marked Drafts presented ‘s “Drawn under (issuing bank) letter of credit number dated .” Office and in the aggregate, Drawings honored by the issuing bank or confirming bank under this letter of credit shall not, P.O. Address exceed the total amount of credit set forth above, or as modified by accepted amendments, and each drawing honored by the issuing bank or confirming bank shall reduce the amount set forth pro tanto. Partial drawings are permitted. Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: 440-3640 (7/03/DCBS/WCD/WEB) American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. Letter of Credit Number Page 2 : Calendar No. The purpose of this letter of credit is to create a primary obligation on the part of Plaintiff(s) : JUDICIAL SUBPOENA (issuing bank) and any confirming bank to the Oregon Department of Consumer and Business Services relating to the self-insured workers’ -against: compensation liabilities and obligations of the self-insured employer (applicant) : in accordance with Chapter 656 of the Oregon Revised Statutes. Except as stated herein, this letter of credit is not subject to any condition or qualification and is the issuing and any confirming bank’s individual obligation which is in no way contingent upon reimbursement. : This letter of credit will be automatically extended without amendment for one year from the expiry date shown above, or any future expiry date, unless at least 60 days prior to expiry, we notify the beneficiary by registered mail or overnight delivery that we elect not to Defendant(s) : extend this. letter .of . . . . .for.such additional period. .The . . . . . . . . . . . be addressed to the Administrator, Workers’ Compensation . . . . . . . . . . credit . . . . . . . . . . . . . . . . . . notification will . . . . . . Division, Department of Consumer and Business Services, State of Oregon, 350 Winter Street NE, P.O. Box 14480, Salem, OR 973090405. Payment of any amount under this letter of credit by the issuing or a confirming bank shall be made by wire transfer to the Oregon THE PEOPLE OF THE STATE OF NEW account, Department of Consumer and Business Services’ bankYORK as instructed in the demand notice signed by the director or the administrator or their designated authorized representative, for deposit to the account of the Oregon Department of Consumer and Business Services for the self-insured employer’s workers’ compensation liabilities and obligations under ORS 656. TO If the issuing bank or any confirming bank is closed at the time of the expiry of this letter of credit for any reason that would prevent the delivery of a demand notice during its normal hours of operation, this letter of credit will be automatically extended for a period of 30 days commencing on the next day of operation. GREETINGS: All bank charges for this letter of credit are for the account of the applicant. WE COMMAND YOU, that all business beneficiary. Any amendments to this letter of credit must be approved by the and excuses being laid aside, you and each of you attend before , the Honorable at the Court Except so far as otherwise expressly stated,located at credit is subject to the International Standby Practices 1998 (ISP 98) International this letter of County of Chamber of Commerce Publication # 590 and to the laws of the state of Oregon. In the event of a conflict between these authorities, the in of the , on the , 20 , at o'clock in the noon, and at any recessed lawsroom state of Oregon will control. day of or adjourned date, to testify and give evidence as a witness in this action on the part of the We hereby engage with drawers, endorsers, and/or bona fide holder that drafts drawn under and presented in strict conformity with the terms of this credit will be duly honored on presentation to us. The funds provided by this letter of credit are not construed to be an asset of the self-insured employer. If any legal proceedings are Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable initiated with respect to this letter of credit, it is agreed that such proceedings shall be subject to the courts and law of the state of Oregon. to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a is requested to add its confirmation to this letter of credit. result of your failure to comply. (name of confirming bank or N/A) Issuing bank Witness, Honorable Name: County, Court in , one of the Justices of the day of , 20 Date: Title: Signature: (Attorney must sign above and type name below) hereby undertakes to honor any drafts presented to it when (name of confirming bank or N/A) drawn under and in strict conformity with the terms of this credit. Confirming bank Name: Attorney(s) for Date: Title: Signature: Office and P.O. Address Accepted by the Oregon Department of Consumer and Business Services Name: Date: Title: Signature: 440-3640 (7/03/DCBS/WCD/WEB) Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com