UNITED STATES OF AMERICA
SOCIAL SECURITY ADMINISTRATION
To __________________________
You are hereby required to appear before _________ , a _________
of the Social Security Administration at ________________
in the City of _______________
State of ______________
day of __________ , 20 __ at ___ o'clock __ M,
to give testimony in connection with:
You are further required to bring with you and produce at said time and place the
following books, correspondence, documents, and records:
Failure to comply with this subpoena will cause action to be taken pursuant to section
205(e) of the Social Security Act, as amended (Title 42 U.S. Code, sec. 405(e)), the
text of which is set forth on the reverse hereof, to compel such compliance.
In testimony whereof, the seal of the
Social Security Administration
is affixed hereto and the undersigned
Regional Commissioner of the Social
Security Administration or an officer
designated by him, has hereunder set his
hand, at ______ this ___ day of ____ , 20
___ .
(Name) _________
(Title)
In case of contumacy by, or refusal to obey a subpoena duly served upon any person,
any district court of the United States for the judicial district in which said person
charged with contumacy or refusal to obey is found or resides or transacts business,
upon application by the Board, shall have jurisdiction to issue an order requiring
such person to appear and give testimony, or to appear and produce evidence, or both,
any failure to obey such order of the court may be punished by said court as contempt
thereof.
The powers and functions of the Social Security Board as defined in section 205(e),
have been delegated to the Commissioner of Social Security and by him to, among others,
the Regional Commissioners of the Social Security Administration. 33 F.R. 5836, 36
F.R. 13941.
RETURN OF SERVICE
_________ , being duly sworn, deposes and says that a copy of this subpoena was served
by him upon ________ on the _____ day of _____ 20 __ by (Check method used):
_______ Personally giving a copy to __________
(Name of Person Served)
________________________
(Title of person served if service on corporation)
at ___________________
(Place of service)
_______ Send a copy by certified mail to ________
at ______________
(Place to which copy mailed)
and the return receipt therefore is attached hereto; and that he was duly authorized
to do so.
Date: ________
_______________
(Name of person making service)
_______________
(Title)
Sworn to before me this
_____ day of ___ , 20 __