Department of Workers' Claims

DEPARTMENT OF WORKERS' CLAIMS FRANKFORT, KENTUCKY 40601

SUBPOENA

Commonwealth of Kentucky ) ) ss County of ______)

To the Sheriff of County, Commonwealth of Kentucky, greetings:

You are hereby commanded to summon ______to appear before the Administrative Law Judge, Department of Workers' Claims,

Commonwealth of Kentucky, at ______, in the County of ___

______, State of Kentucky, on the _____ day of ______, 200___, at the hour of ______.M. (local time), to give evidence in a certain proceeding now pending before said Department of Workers' Claims wherein ______is the Plaintiff and ______is the Defendant.

Witness the hand of said department this ______day of ______, 200___

DEPARTMENT OF WORKERS' CLAIMS COMMONWEALTH OF KENTUCKY

By: ______Administrative Law Judge