Subpoena For Production Of Records (And/or) Witness Subpoena
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State of Michigan
Department of Licensing and Regulatory Affairs
SUBPOENA FOR PRODUCTION OF RECORDS
Michigan Administrative Hearing System/
(and/or) WITNESS SUBPOENA
Workers’ Compensation Agency
P.O. Box 30016, Lansing, MI 48909
Plaintiff
Defendant(s)
v
Last 4 digits of injured worker’s social security number:
TO:
YOU ARE ORDERED:
1. to produce on or before ________________________ the following records, papers, books and documents, or
make the materials reasonably available for copying when received:
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.
If you refuse to obey this subpoena, refuse to be sworn or testify, or fail to produce 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 and for which purpose the court is given jurisdiction.
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.
DO NOT SEND RECORDS TO THE WORKERS’ COMPENSATION AGENCY OFFICE
All items specified in Number 1 above are to be forwarded to:
Name of attorney/party requesting subpoena (please print or type)
Representing
P Number
Email
Telephone Number
Street Address
City
State
ZIP Code
By requesting this subpoena, the attorney/party certifies that the matter about which this subpoena is issued is pending
before the Agency and is issued in compliance with MCL 418.853 and Rule 418.56.
This subpoena must be signed by an Attorney of Record, Magistrate, Workers’ Compensation Agency Director, or
Chair of the Michigan Compensation Appellate Commission.
Name (please print or type)
P Number
Signature
Date
Plaintiff Attorney Name, P#, Address, Phone
Defendant Attorney Name, P#, Address, Phone
Defendant Attorney Name, P#, Address, Phone
LARA is an equal opportunity employer/program. Auxiliary aids,
Authority:
Workers’ Disability Compensation Act 418.853; 2007 MR 4; R418.56
services and other reasonable accommodations are available
Completion:
Voluntary
upon request to individuals with disabilities.
Penalty:
Contempt
WC-508 (Rev. 1/12) Front
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