COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR AND INDUSTRY BUREAU OF WORKERS' COMPENSATION 1171 S. CAMERON STREET, ROOM 103 HARRISBURG, PA 17104-2501 (TOLL FREE) 800-482-2383 -against- Employee First Name ANSWER TO PETITION FOR COMMUTATION Plaintiff(s) Index No. Social Security Number: : Calendar No. Date of Injury: MM DD : PA BWC Claim Number: JUDICIAL YYYY SUBPOENA (IF KNOWN) : Employer Last Name Name : Street 1 Street 1 Street 2 Street 2 : State Zip Code Defendant(s) City/Town : ...................................................... City/Town County Telephone State Zip Code County Telephone FEIN Dependent THE PEOPLE OF THE STATE OF NEW YORK First Name Street 1 Last Name VS. TO Insurer or Third Party Administrator (if self-insured) Name Street 2 Street 1 City/Town State Zip Code GREETINGS: County Street 2 Telephone City/Town WE COMMAND YOU, that all business and excuses being laid aside, you and eachState youZip Code before of attend , the Honorable at the Telephone Court Bureau Code located at County of in room , on the day of , 20 , County 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 Claim Number FEIN Your failure to comply with this subpoena is punishable as a contempt of court and ¨ make you liable to will ¨ Notice of Compensation Payable Agreement the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a ¨ Supplemental Agreement ¨ Award result of your failure to comply. TO YOUR HONORABLE JUDGE: Witness, Honorable , one of the Justices of the In answer to the petition presented to your Honorable Judge by Court in County, day of , 20 Compensation Presently Payable Under: requesting commutation of future installments of compensation payable in the captioned case, (I)(we) submit for your consideration the following facts: (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address NOTICE: This answer should be clearly completed (preferably typed) and original mailed to the office of the Judge to Telephone No.: whom the case is assigned. Note: This answer may be signed by any party in interest for themselves and all other parties in interest. Facsimile No.: (OVER) LIBC-35 REV 12-97 E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. LIBC-35 : : (I)(we) further submit for your consideration the following additional facts: Plaintiff(s) -against- Calendar No. JUDICIAL SUBPOENA : : : Defendant(s) : ...................................................... For the above reasons, (I)(we) request that your Honorable Judge mutation in the captioned case. the said petition for com- THE PEOPLE OF THE STATE OF NEW YORK TO PLEASE ENTER MY APPEARANCE FOR DEFENDANT: Attorney Defendant GREETINGS: First Name Last Name First Name Last Name Signature Firm Name WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Street 1 Court located at County of Date: YYYY inMM room DD , on the day of , 20 Street 2 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witnessCity/Town action on the part of the State in this Zip Code Attorney Signature Date: Telephone PA Attorney ID Number Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to MM DD YYYY 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 Court in County, , one of the Justices of the day of , 20 Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 of the Pennsylvania Workers' Compensation Act and may also be subject to criminal and civil penalties through Pennsylvania Act 165 of 1994. (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com