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Fill and Sign the Contact the Division of Labor Standardsmissouri Labor Form

Fill and Sign the Contact the Division of Labor Standardsmissouri Labor Form

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+ WC-25 -A WC-25 -A (04-12) AI MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS 3315 West Truman Blvd., P.O. Box 58 Jefferson City, MO 65102- 0058 + INJURY NUMBER - THE STATE OF MISSOURI, To You are hereby commanded to be and appear personally before the Division of Workers’ Compensation, Department of Labor and Industrial Relations, at the hour of M., on , at in , Missouri, to testify on the hearing of a Claim for Compensation under the Missouri Workers’ Compensation Law between , employee (or dependent), , employer, and , insurer, in behalf of the , and you are further commanded to bring with you, and then and there produce in evidence , and hereof fail not at your peril. Given by order of the Division of Workers’ Compensation, Department of Labor and Industrial Relations, with the seal of the Division of Workers’ Compensation of the Department of Labor and Industrial Relations of the State of Missouri affixed, at the City of , Missouri, this day of . DIVISION OF WORKERS’ COMPENSATION (SEAL) By Director/Administrative Law Judge (Over) SUBPOENA DUCES TECUM WC-25 -A-2 (04-12) AI RETURN STATE OF MISSOURI ss. of being duly sworn, on his oath states that he served the within subpoena in the City of Missouri, on the day of , by delivering a true copy thereof to the within named Subscribed and sworn to before me, this day of My term expires Notary Public

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