COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Calendar PROOF OF CLAIM ADDENDUM (POC Form 3) No. : JUDICIAL SUBPOENA EMPLOYEE NAME ____________________________________________________________________________________________ Plaintiff(s) -against- : Check only 1 box on this form. You must complete this form for each benefit requested. : Temporary Disability Permanent Disability : Current Medical Care Future Medical Care Defendant(s) : . . . .Other ____________________________________________________________________________ .................................................. AMOUNT CLAIMED $ THE PEOPLE OF THE STATE OF NEW YORK Describe the basis for the amount claimed for this benefit. You may attach supporting documents as appropriate. If you attach a TO supporting document, YOU MUST PLACE AN EXHIBIT NUMBER ON THE DOCUMENT AND IDENTIFY THE DOCUMENT WITH THE EXHIBIT NUMBER ON THIS FORM. (For example: “See attached EXHIBIT 2, Doctor’s Report dated 02/02/02”.) _______________________________________________________________________________________________________________________________________ GREETINGS: _______________________________________________________________________________________________________________________________________ WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before _______________________________________________________________________________________________________________________________________ , the Honorable at the Court located at County of _______________________________________________________________________________________________________________________________________ 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 _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to _______________________________________________________________________________________________________________________________________a the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as result of your failure to comply. _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ Witness, Honorable Court in County, , one of the Justices of the _______________________________________________________________________________________________________________________________________ day of , 20 _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ (Attorney must sign above and type name below) _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ Attorney(s) for _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ Office and P.O. Address _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ Telephone No.: _______________________________________________________________________________________________________________________________________ Facsimile No.: E-Mail Address: _______________________________________________________________________________________________________________________________________ [POC Form 3, Rev. 2002.02.14] Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com