(Caption)
NOTICE
TO__________ (Name of person to be served)
The enclosed subpoena is served pursuant to Title 40 Pa. Code § 15.48(b)(3). Complete the acknowledgment part of this form and return the copy of the completed form to the sender in the enclosed self-addressed, stamped envelope.
Sign and date the acknowledgment. If you are served on behalf of a partnership, unincorporated association, corporation or similar entity, indicate under your signature your relationship to that entity. If you are served on behalf of a person and you are authorized to receive the subpoena, indicate under your signature your authority.
Date Notice Mailed: _______________________________________________________________________________________________
_______________________________________________________________________________________________
Party serving subpoena or
Attorney for Party
ACKNOWLEDGMENT OF RECEIPT OF SUBPOENA
I acknowledge receipt of a copy of the subpoena in the above captioned matter and shall appear as directed.
Date: _______________________________________________________________________________________________
Signature _______________________________________________________________________________________________
Relationship to entity or
Authority to receive the subpoena
40 Pa. Code § 15.48