Fill and Sign the Dedimus Form

STATE OF ILLINOIS ) ) COUNTY OF       ) ILLINOIS WORKERS’ COMPENSATION COMMISSION DEDIMUS POTESTATEM       Case #       WC       Employee/Petitioner v.             Employer/Respondent TO:       Because it has been represented to us that each of the individuals listed below: ( List each name and address)       is a necessary witness in this case and cannot appear at the Commission hearing, we appoint you to examine each witness under oath and to take his or her deposition in response to all oral written questions posed by the petitioner or respondent at the following time and place:       and to certify each deposition to: Data Entry Unit, Illinois Workers’ Compensation Commission, 100 W. Randolph St. #8-200, Chicago, IL 60601. ________________________________________________       Signature of arbitrator or commissioner Date IC33 12/04 100 W. Randolph Street #8-200 Chicago, IL 60601 312/814-6611 Toll-free 866/352-3033 Web site: www.iwcc.il.gov Downstate offices: Collinsville 618/346-3450 Peoria 309/671-3019 Rockford 815/987-7292 Springfield 217/785-7084 P ROOF OF S ERVICE If the person who signed the Proof of Service is not an attorney, this form must be notarized. I,       , affirm that I delivered mailed with proper postage in the city of       a copy of this form at       AM on       to each party at the address(es) listed below.       _______________________________________ Signature of person completing Proof of Service Signed and sworn to before me on ________________ _________________________________________ Notary Public IC33 page 2