Free IC33 - Illinois

STATE OF ILLINOIS

) ) COUNTY OF __________________ )

ILLINOIS WORKERS' COMPENSATION COMMISSION
DEDIMUS POTESTATEM

__________________________________________
Employee/Petitioner v.

Case # ________ WC ____________________

__________________________________________
Employer/Respondent

TO:

Because it has been represented to us that each of the individuals listed below:

(List each name and address)

_________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________

is a necessary witness in this case and cannot appear at the Commission hearing, we appoint you to examine each witness under oath and to take his or her deposition in response to all oral ____ written questions ____ posed by the petitioner or respondent at the following time and place:
_________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________

and to certify each deposition to: Data Entry Unit, Illinois Workers' Compensation Commission, 100 W. Randolph St. #8-200, Chicago, IL 60601.

___________________________________________________ Signature of arbitrator or commissioner

____________________________ Date

IC33 12/04 100 W. Randolph St. #8-200 Chicago, IL 60601 312/814-611 Toll-free 866/352-3033 Web site: www.iwcc.il.gov Downstate offices: Collinsville 618/346-3450 Peoria 309/671-3019 Rockford 815/987-7292 Springfield 217/785-7084

P ROOF OF S ERVICE
If the person who signed the Proof of Service is not an attorney, this form must be notarized.

I, ________________________________ , affirm that I delivered _____ mailed with proper postage _____ in the city of _________________________________ a copy of this form at ___________ AM on ___________________ to each party at the address(es) listed below.

____________________________________________
Signature of person completing Proof of Service

Signed and sworn to before me on __________________

___________________________________________
Notary Public

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