COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : South Dakota Department of Labor Division of Labor and Management Claim Administrator Information: -against- : Plaintiff(s) Index No. Calendar No. MEMORANDUM OF PAYMENT FOR REHABILITATION JUDICIAL SUBPOENA : Claim Administrator Federal ID No _________________________ Carrier Code ______________ Claim # ______________ : Name (DBA) _____________________________________________ : Address ________________________________________ City _______________________ State _______ Zip ____________ Defendant(s) : ...................................................... Telephone Number _______________________ Form Completed By ______________________________________________ Employer Information: THE PEOPLE OF THE STATE OF NEW YORK Employer Federal ID No ________________________ Employer Name (DBA) ______________________________________ TO Employee/Injury Information: Employee/Claimant SSN __________________________ Date of Injury _______________________ GREETINGS: Body Part(s) Injured ________________ ________________ _______________ ______________ WE COMMAND YOU, that all business and excuses being laid aside, you and each of _______ Employee/Claimant Name ______________________________________ ____________________________ you attend before (Last) the Honorable Retraining/Rehabilitation Information: at located County of in room , on the day of (First) Court at the , 20 , at o'clock in the (MI) noon, and at any recessed Claimant’s Gross Average testify and give evidence as a witness in this action on the part of the or adjourned date, to Weekly Wage _________________________ Claimant’s compensation rate is $ _______________________________ Compensation to be paid for rehabilitation (SDCL 62-4-5.1) is $ __________________________ Your failure on the following information: The compensation is based to comply with this subpoena is punishable as a contempt of court and will make you liable to 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. The employee is unable to return to his/her usual and customary occupation as of _______________________________ The program of retraining will begin on _________________________ and end on ______________________________ The program of rehabilitation will begin on ________________________________one of the Justices of the Witness, Honorable , County, day of , 20 TheCourt in to be undertaken is as follows: (Give a brief description of the program) __________________________ program ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ (Attorney must sign above and type name below) If additional medical treatment is required in the future as a result of such injury, the employer/insurer shall be obligated to pay such future medical expenses. Attorney(s) for This memorandum is a receipt only. It does not constitute an agreement, stipulation or release. The Division of Labor and Management retains jurisdiction as to all issues. The employee does not waive his/her right to pursue any benefits to which he/she may be entitled. Claimant/Employee Signature ______________________________________________________ Date __________________ Office and P.O. Address Claim Administrator Signature _____________________________________________________ Date __________________ Division of Labor and Management Approval by ___________________________________________ Date _____________ DOL-LM-113 Revised 06/06/2003 Telephone No.: form to: Submit Facsimile No.: E-Mail Address: Mobile Tel. No.: South Dakota Department of Labor Division of Labor and Management 700 Governors Drive Pierre, SD 57501-2291 Telephone (605)773-3681 American LegalNet, Inc. www.USCourtForms.com ,