COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Calendar No. SOUTH DAKOTA DEPARTMENT OF LABOR : DIVISION OF LABOR AND MANAGEMENT JUDICIAL Plaintiff(s) Kneip Building, Third Floor -against700 Governors Drive : Pierre, South Dakota 57501-2291 : Telephone: 605-773-3682 SUBPOENA WAGE COMPLAINT : Defendant(s) : NAME OF EMPLOYEE: ___________________________________________________ ...................................................... HOME ADDRESS: _______________________________________________________ DATE OF BIRTH: _______________ SOCIAL SECURITY #: ________________ THE PEOPLE OF THE STATE OF NEW YORK OTHER: (____)____________ TELEPHONE #: HOME: (____)____________ TO NAME OF EMPLOYER: (Owner/Partners/Corporation) ______________________________________________________________________ GREETINGS: NAME OF BUSNESS: (As listed in telephone or other directory) ______________________________________________________________________ attend before WE COMMAND YOU, that all business and excuses being laid aside, you and each of you , the Honorable OF BUSINESS: ________________________________________________ at the Court ADDRESS located at County of TELEPHONE #: (____)___________ 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 IS BUSINESS STILL IN OPERATION? YES_____ NO____ IF NO, DATE BUSINESS CEACED OPERATION: ______________________________ Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to IS BUSINESS IN BANKRUPTCY? YES_____ for a maximum penalty of $50 and all damages sustained as a the party on whose behalf this subpoena was issued NO____ HAS BUSINESS to comply. result of your failure FILED OR COMPLETED BANKRUPTCY? YES_____ NO____ IS OWNER IN BANKRUPTCY? YES_____ NO____ HAS OWNER FILED OR COMPLETED BANKRUPTCY? YES_____ NO____ Witness, Honorable , one of the Justices of the IF ANSWER YES TO THE ABOVE QUESTIONS, PLEASE INDICATE DATE AND LOCATION Court BANKRUPTCY:_________________________________________________________ County, day of , 20 OF in DATE OF HIRE: _____________________________ ARE YOU STILL EMPLOYED WITH THIS BUSINESS? YES_____ NO____ and type name below) (Attorney must sign above IF NO, DATE OF TERMINATION:________________ DID YOU: VOLUNTARILY TERMINATE___________ TERMINATED BY EMPLOYER_________ Attorney(s) for LAID OFF__________ DID ANY WRITTEN CONTRACT OF AGREEMENT EXIST BETWEEN YOU AND THE NAMED EMPLOYER? YES_____ NO____ (If yes, please attach a copy) Office and P.O. Address WHAT DID EMPLOYER AGREE TO PAY UPON HIRING: $_______ HOUR $_______ MONTH $_______ YEAR (Please complete second page also.) PAY DAYS WERE: Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Calendar No. WEEKLY_______ BI-MONTHY_______ MONTHLY_______ OTHER_______ : IF OTHER, PLEASE EXPLAIN: _______________________________________ JUDICIAL SUBPOENA Plaintiff(s) -against: RATE OF PAY AT THE TIME OF TERMINATION: $_______ HOUR $_______ MONTH $_______ YEAR : WAS THERE EVER A SPECIFIC WRITTEN RATE OF PAY AGREEMENT? : YES____ NO_____ (if yes, please attach a copy) Defendant(s) : . .TOTAL .AMOUNT .OF. WAGES, .SALARY, .ECT. .DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $____________________________ HOW THIS AMOUNT WAS CALCULATED: (Attach any supporting documents i.e timecards, paystubs, ect.)____________________________________________________________ THE PEOPLE OF THE STATE OF NEW YORK ____________________________________________________________________________ TO ________ DATE PAYMENT WAS REQUESTED FROM EMPLOYER: ___________________ WAS THIS REQUEST IN WRITING: YES____ NO____ GREETINGS: DO YOU OWE EMPLOYER FOR GOODS OR SERVICES PURCHASED, OR CASH ADVANCES? YES_____ NO____ AMOUNTand excuses being laid aside, you and each of you attend before WE COMMAND YOU, that all business OWED: $__________ REPAYMENT PLAN: __________________________________________________ , the Honorable at the Court located at County of HAVE ANY PROPERTY OF THE EMPLOYER IN YOUR POSESSION? DO YOU inYES____ NO____ the room , on 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 PLEASE LIST ADDITIONAL DETAILS OR EXPLANATION AND SUPPORTING DOCUMENTS. USE ADDITIONALto complyIF NECESSARY. is punishable as a contempt of court and will make you liable to Your failure SHEET with this subpoena 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 , one of the Justices of the Court in County, day of , 20 The information furnished is confidential and will be used only by the Division of Labor and Management for the purpose of investigation of this matter. ANY EMPLOYEE WHO SHALL FALSIFY THE AMOUNT DUE HIMSELF OR WHO INTENTIONALLY ATTEMPTS name below) (Attorney must sign above and type TO DEFRAUD THE EMPLOYER HAS COMMITED A CLASS 2 MISDEMEANOR. If this matter is resolved in whole or in part at any time, please notify this office immediately at Attorney(s) for (605) 773-3682. ________________________________ SIGNATURE DATE DOL-LM-8/02 Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com