COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : : Plaintiff(s) -against- Calendar No. JUDICIAL SUBPOENA : : : Defendant(s) : ...................................................... Dispute Resolution Form THE PEOPLE OF THE STATE OF NEW YORK Date: ____________________ TO From: Name: Address: GREETINGS: _______________________ _______________________ WE COMMAND YOU, _______________________ that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court _______________________ County ofTelephone Number: located at 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 RE: Claimant Name: ________________________ Date of Injury: _________________________ Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Claim Number: _________________________ 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. Employer: _________________________ Witness, Honorable Description and County, Summary of Dispute: Court in day of , one of the Justices of the , 20 (Attorney must sign above and type name below) Attorney(s) for Please attach any supporting documentation that should be considered. Please submit to: Marijo Storment, The ALARIS Group, Inc. PO Box 207, Garretson, SD 57030. 605-594-8160. It is the goal of the case management plan to resolve this Officewithin 30Address receipt of this issue and P.O. days of form. At that time, should resolution not be achieved, or there continues to be dissatisfaction of the results, an appeal may be made to the South Dakota Department of Labor. Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com