Free Plaintiff - Michigan

Go to Page 2
State of Michigan Department of Labor & Economic Growth Workers' Compensation Agency/Board of Magistrates P.O. Box 30016, Lansing, MI 48909

Print

Reset

SUBPOENA FOR PRODUCTION OF RECORDS (and/or) WITNESS SUBPOENA
Defendant(s) v

Plaintiff

(include last 4 digits of social security number)

In the name of the People of the State of Michigan

TO:

YOU ARE ORDERED:
1. to produce on or before ________________________ the following records, papers, books and documents:

2. to appear personally before ____________________________ on: Date: Time: Location: 3. to both produce the items designated in Number 1, and to appear personally as outlined in Number 2. All items specified in Number 1 are to be forwarded to:
(DO NOT SEND RECORDS TO ANY WORKERS' COMPENSATION AGENCY OFFICE)

Note: If copies of business/medical records are mailed, the records custodian shall complete the certificate on the backside of this subpoena and attach a complete copy of the original business/medical records to the subpoena.

If you fail to produce or appear without such material as you have been ordered to produce, you may be found guilty of contempt and punished accordingly in any circuit court within whose jurisdiction the offense is committed. Signed this ______________ day of _____________________, 20___. I certify that this subpoena meets the requirements of R418.56. WORKERS' COMPENSATION AGENCY

Signature ____________________________
(Party requesting subpoena)

__________________________________ Magistrate or Director
Defendant Attorney Name, P#, Address, Phone

Plaintiff Attorney Name, P#, Address, Phone

Defendant Attorney Name, P#, Address, Phone

The Department of Labor & Economic Growth will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status, disability, or political beliefs. If you need assistance with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this agency. If you require special accommodations to use the hearings office because of a disability or if you require a foreign language interpreter to help you to fully participate in any proceedings, please contact the agency immediately. WC-508 (Rev. 2/07) Front (Prior versions obsolete)

Authority:

Workers' Disability Compensation Act 418.853; R418.56 Completion: Voluntary Penalty: None

Plaintiff

(include last 4 digits of social security number)

Defendant(s) v

CERTIFICATE OF RECORDS CUSTODIAN
_________________________________, the undersigned after being sworn, states the following: 1. That I am the
(Your position)

of
(Organization)

and in such capacity I am the custodian of the business/medical records for this organization. 2. That on ____________________, I was served with a subpoena in connection with this claim, calling for the
(Date)

production of business/medical records pertaining to _____________________________________________. 3. 4. That I reviewed the original of the records and made a true and exact copy of the original records and that the attached copies of the original records are true and complete. If submitting medical records, it is the regular practice of this organization to contemporaneously and timely record information concerning the treatment and care of the patient and I have attached the records that have been prepared and kept concerning this patient. Date _______________________________

Signature _________________________________________________

Subscribed and sworn to before me on ________________________, ______________________________ County, Michigan.
Date

My commission expires ______________________
Date

Signature ___________________________________________________
Notary Public

AFFIDAVIT OF MAILING/PROOF OF SERVICE
I certify that on ___________________ a copy of this subpoena with a witness fee and mileage fee was
Date

mailed to the other party(ies) or their attorney(s), securely sealed with full-rate postage attached and deposited with the United States Postal Service. personally served. Signature _________________________________________________ Date _______________________________

Subscribed and sworn to before me on ________________________, ______________________________ County, Michigan.
Date

My commission expires ______________________
Date

Signature __________________________________________________
Notary Public

WC-508 (Rev. 2/07) Back

Go to Page 1