Subpoena For Production Of Records (And/or) Witness Subpoena Page 2
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1
2Plaintiff
Defendant(s)
v
Last 4 digits of injured worker’s social security number:
CERTIFICATE OF RECORDS CUSTODIAN
, the undersigned after being sworn, states the following:
1.
That I am the
of
Your position
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.
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.
4.
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.
Signature _________________________________________________
Date _______________________________
Subscribed and sworn to before me on ________________________, ______________________________ County, Michigan.
Date
My commission expires ______________________
Signature ___________________________________________________
Date
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 ______________________
Signature __________________________________________________
Date
Notary Public
WC-508 (Rev. 1/12) Back
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