Attorney  Name:_____________________________________________________

          Firm Name:________________________________________________________

          Address:___________________________________________________________

          City/State/Zip:______________________________________________________

          Telephone:_________________________________________________________

          Fax:______________________________________________________________

         

          Paralegal:__________________________________________________________

          Office Manager:_____________________________________________________

           Please verify with respondents any fees required for record retrieval and submit the required payment with the subpoena.

 
           How would you like to be statused?
                Phone___________        Fax___________            Mail___________

           Would you like an Affidavit of No Record, when a facility has No Records?
                    Yes_________       No___________

 
Special Instructions: ___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________
Please Attach Any Additional Information.