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STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS DIVISION OF INDUSTRIAL ACCIDENTS WORKER'S COMPENSATION APPEALS BOARD Case No. (IF APPLICATION HAS BEEN FILED CASE NUMBERMUST BE INDICATED REGARDLESS OF DATE OF INJURY) SUBPOENA DUCES TECUM Claimant/Applicant vs. (When records are mailed, identity them by using abovecase number or attaching a copy of a subpoena) Employer/insurance Carrier/Defendant People of the State of California Send Greetings to: We COMMAND YOU to appear before: at M to testify in the above- on the day of o'clock , at entitled matter and to bring with you and produce the following described documents, papers, books, records: (Do not produce X-rays unless specifically mentioned above.) For failure to attend as required, you may be deemed guilty of contempt and liability to pay to the parties aggrieved alllosses and damages sustained thereby and forfeit one hundred dollars in addition thereto. This subpoena is issued at the request of the person making the declaration on the reverse hereof, or on the copy which isServed herewith. Date WORKERS' COMPENSATION APPEALS BOARD OF THE STATE OF CALIFORNIA Date SEE REVERSE SIDE [SUBPOENA INVALID WITHOUT DECLARATION] This subpoena does not apply to any member of the Highway Patrol, Sheriffs Office or city Police Department unless accompanied by notice from theBoard that deposit of the witness fee has been made in accordance with Government code 6809 7.2, at seq. DIA WCAB 32 (Side 1) (Rev. 06/94) You are directed to make the original records available for inspection and copying at the address of the Deposition officer given above or, with the consent of the DepositionOfficer, at your place of business during normal business hours in accordance withCalifornia Evidence Code Section 1560(e). Do not release the requested records to theDeposition Officer prior to the date and time stated above. DECLARATION FOR SUBPOENA DUCES TECUM Case No. STATE OF CALIFORNIA, COUNTY of The undersigned states: that he/she is (one o f) the attorney (s) of records/representative (s) for the applicant/defendant in the action captioned On the reverse hereof That has in his/her possession or under his/her control the documents described on the reverse hereof. That the said documents are material to the issues involved in the case for the following reasons: Declaration for Injuries on or After January 1, 1990 and Before January 1,1994 That an Employee's Claim for Worker's Compensation Benefits (DWC Form 1) has been filed in accordance with Labor Code Section 5401 by the alleged injured worker whose records are sought, or if the worker is deceased, by the dependent (s) of the decedent, and that a true copy of the form filed is attached hereto. (Check box if applicable and part of declaration below. See instructions on front of subpoena) Executed on , California. , at Address Telephone Signature DECLARATION OF SERVICE STATE OF CALIFORNIA, County of I, the undersigned, state that I served the foregoing subpoena by showing the original and delivering a true copy thereof, together with a copy of the Declaration in support thereof, to each of the following named persons, personally, at the date and place set forth opposite each name. Date Name of Person Served Place I declare under penalty of perjury that the foregoing is true and correct. Executed on , at , California. Signature DWC WCAB 32 (Side 2) (Rev. 09/94)