OGC will inform either the Dallas CfD or the DO as to the action taken. When OGC responds
in writing, a copy of any letter or other document from OGC to the attorney who issued
the subpoena or to the court will also be sent to the RO, which will then send a copy
of the response to the DO.
SUBPOENA/COURT ORDER QUESTIONNAIRE
FAX to (214) 767-1452
Numberholder: _____________ SSN: ____- __- ________
Is the NH deceased? Yes ___ No ____
A child? Yes ___ No ____
Person reporting subpoena: ______________________________
Location: __________________ Phone: (_____) ______-_____
Date and time received: ______________________________________
Subpoena served: By mail? __ Or in person? __ By whom? __________________
If personally served, were you asked to sign a statement or form that acknowledges
and/or accepts the subpoena? Yes ____ No ____
NOTE: If the subpoena arrived in the mail and included a waiver of personal service, do
not sign and return the waiver.
Date: ______/ ______/ ______ Time: _________AM/PM
Place: Court? _______ Atty's Ofc? _______ SSA/DDS _____
If the attorney's name, address and phone number do not appear on the subpoena, call
the clerk of the court. If the subpoena is from a small claims court, there probably
will be no attorney.
Phone: (_____) ________- _________________
Is consent required to disclose the information requested? Yes __ No __
If yes, was a valid consent provided?
(See criteria in GN 03305.001): Yes ___ No ___
Title II ____________________________________________________
Title XVI ___________________________________________________
NOTE: Do not request transfer of the folder(s) unless a valid consent has been provided
or the RO asks you to initiate retrieval.
Date and time the subpoena was faxed to Dallas CfD/RO (FAX 214-767-1452): _____/_____/______
Fax to the Dallas RO the subpoena and any accompanying documents, together with a
copy of this questionnaire.
DALLAS CfD REFERRAL TO OGC
Referred to Dallas OGC on ____/___/____ (Date) at ___:____ AM/PM