IN THE COURT OF COMMON PLEAS DAUPHIN COUNTY, PENNSYLVANIA No. Civil Action - Medical Professional LiabilityAction : : : : : : : : vs : : : : : : : : Plaintiff(s) & Address(es) Defendant(s) & Address(es) PRAECIPE FOR WRIT OF SUMMONS TO THE PROTHONOTARY OF SAID COURT: Please issue writ of summons in the above-captioned action. Writ ofm Sumons shall be issued and forwarded to Attorney Sheriff Signature of Attorney Supreme Court ID No. Date: Name/Address/Telephone No. of Attorney WRIT OF SUMMONS TO THE ABOVE NAMED DEFENDANT(S) YOU ARNE OHTIFIED TAT THE ABOVE-NAMEDF PLAINTIFH(S) HAS/AVE COMMENCED AN ACTION AGAINST YOU. Prothonotary Date: by Deputy Check here if reverse is ised for addisu tional information. Prothon. - 55 American LegalNet, Inc. www.USCourtForms.com