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STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS DIVISION OF WORKERS ’ COMPENSATION WORKERS’ COMPENSAT I ON APPEALS BOARD Case No. _________________________________________ ( IF APPLICATION HAS B EEN FILED , CASE NUMBER MUST BE INDICATED REGARDLESS OF DATE O F INJURY ) vs. Claimant/Applicant Employer/Insurance Carrier/Defendant S UBPOENA The People of the State of California Send Greetings to: Y OU ARE H EREBY C OMMANDED to appear before a Workers’ Compensation Judge of the WORKERS’ COMPENSATION APPEALS BOARD OF THE STATE OF CALIFORNIA AT on the ______ _______ day of ____ __________________________ , at ___ _____ o’clock ___ . M., to test if y in the above - entitled action . For failure to attend as required, you may be deemed guilty of a contempt and liable to pay to the parties aggrieved all losses and damages sustained thereby and forfeit one hundred dollars in addition thereto. This subpoena is issued at the request of , Telephone No. . This subpoena is issued at the request of the person making the declaration on the reverse hereof, or on the copy whi ch is se rved herewith. WORKERS’ COMPENSATION APPEALS BOARD OF THE STATE OF CALIFORNIA Secretary, Assistant Secretary, Workers’ Compensation Judge Date : Thi s subpoena does not apply to any member of the Highway Patrol, Sheriff's Office or city Police Department unless accompanied by notice from this Board that deposit of the witness fee has been made in accordance with Government Code 68097.2, et seq. FOR INJURIES OCCURING ON OR AFTER JANUARY 1, 1990, AND BEFORE JANUARY 1, 1994 If no Application for Adjudication of Claim has been filed, a declaration under penalty of perjury that the Employee’s Claim for Workers’ Compensation Benefits (Form DWC - 1) has been filed pursuant to Labor Code Section 5401 must be executed properly. [SUBPOENA INVALID WITHOUT DECLARATION] DWC WCAB 30 (Side 1) (REV. 06/18 ) DECLARATION FOR INJURIES OCCURING ON OR AFTER JANUARY 1, 1990, AND BEFORE JANUARY 1, 1994 , FOR WHICH AN APPLICATION FOR ADJUDICATION OF CLAIM HAS NOT BEEN FILED STATE OF CALIFORNIA, County of Case No . The undersigned states: That he /she is (one of) the attorney(s) of record / representative(s) for the applicant/defendant in the action captioned on the reverse hereof and t hat an Employee's Claim for Workers' Compensation Benefits (DWC Form 1) has been file d in accordance with Labor Code Section 5401 and California Code of Regulations, title 8, section 10120 (Administrative Director’s Rules and Regulations), by the alleged injured worker in this action , or if the worker is deceased, by the de - pendent(s) of the decedent, and that a true copy of the form filed is attached hereto . I declare under penalty of perjury that the foregoing is true and correct Executed on _____________________________________, at ________________________________________________ , California. ______________________________________ _______________________________________ Signature Address Telephone DECLARATION OF SERVICE STATE OF CALIFORNIA, County of I, the undersigned, state that I served the foregoing S ubpoena 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 name d persons, personally, at the da te and place set forth opposite each name. Name of Person Served Date 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. 06/18 )