Fill and Sign the Fillable Online Must Be Indicated Reguardless of Date of Form

STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS DIVISION OF WORKERS ’ COMPENSATION WORKERS’ COMPENSAT ION APPEALS BOARD ________________________________________ Claimant/Applicant, vs. ________________________________________________ Employer/Insurance Carrier/Defendant. Case No. _________________________________________ (IF APPLICATION HAS B EEN FILED , CASE NUMBER MUST BE INDICATED R EGARDLESS OF DATE OF INJURY ) SUBPOENA DUCES TECUM (When records are mailed, identify them by using above case number or attaching a copy of subpoena) Where no application has been filed for injuries on or after January 1, 1990 and before January 1, 1994, subpoena will be valid without a case number, but subpoena must be served on claimant and employer and/or insurance carrier. See instructions below.* The People of the State of California Send Greetings to: WE COMMAND YOU to appear before at on the _____________ day of ______________________________ , at ________ o’clock ___. M., to test ify in the above - entitled matter and to bring with you and produce the following described documents, papers, books and records. (Do not produce X -rays unless specifically mentioned ab ove.) 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 the person making the declaration on the reverse hereof, or on the copy which is served herewith. Dat e ____________________________ __________ WORKERS ’ COMPENSATION APPEAL S BOARD OF THE STATE OF CALIFORNIA Secretary, Assistant Secretary, Workers’ Compensation Judge *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. SEE REVERSE SIDE [SUBPOENA INVALID WITHOUT DECLARATION] You may fully comply with this subpoena by mailing the records described (or authenticated copies, Evid. Code 1561) to the pe rson and place stated above within ten (10) days of the date of service of this subpoena. Thi s subpoena does not apply to any mem ber 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. DWC WCAB 32 (Side 1) (REV. 06/18 ) DECLARATION FOR SUBPOENA DUCES TECUM Case No. STATE OF CALIFORNIA, County of 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. That has in his/her possession or under his/her control the documents described on the reverse hereof. That 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 Workers' 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 s ubpoena.) 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 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 name d persons, personally, at the date 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 )