COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Wisconsin Department of Administration Division of State Agency Services : DOA-6733 (R03/2001) Index No. Bureau of State Risk Management Calendar No. Post Office Box 77008 Madison, WI 53707-7008 Fax (608) 264-8250 : Employee Funding and Coding JUDICIAL SUBPOENA Plaintiff(s) -against- Must Accompany any WKC-12 : To be completed by an Agency Worker’s Compensation Coordinator. : (To properly process each WKC-12 form, it is absolutely essential we have the general funding and coding information for each employee. Please forward this form either by email, or fax with each WKC-12.) : Employee Injury Date (mm/dd/ccyy) Claims Adjuster Org. Code Defendant(s) : ...................................................... THE PEOPLE OF THE STATE OF NEW YORK TO Occupation Code Job Category 1 GPR% 2 3 4 5 Non-GPR% GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court Injury/Illness located at County of A in room B C F I , 20 ,D the E on day of G , 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 Severity 0 1 2 3 4 5 6 7 8 9 Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result No your failure to comply. of Yes OSHA Recordableon the party Witness, Number of Days Lost Court in Honorable County, , one Number of Days Restricted day of of the Justices of the , 20 Occurrence Object Object Code (Attorney must sign above and type name below) Right Left Both Result Location Attorney(s) for By Date (mm/dd/ccyy) Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com