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Subpoena Rec'd 3-30-23 - Ricardo AcevedoTo:CITY OF CUPERTrNO CITY CLERK 10300 TORRE AVE, IF CUPERTINO, CA 95014 Plione' (408) 777-3200 Fax 6020 West Oaks Blvd, Suite 310, Rockliii, CA 95765 Phone: (877) 739-7481 Fax: (707) 204-6527 ' . Dgte: 3/28/2023 Reference Number: 1090761 Records Subject: Ricardo Acevedo Date of Birth: 1/1/1991 SSN: Dates Requested: Records Requested: Wage/Employment (please see Attac)iment 3 for specific records requested) Q E C EnV[E MAR 3 0 2,02'.i o i-!- CUPERTI O CiT't' :')i..ERK To avoid contempt, the Affidavit of Custodian of Records must be completed whether the requested records are in your possession or not (Evid. Code §1561(a)(b)). You do not have to appear. YOLI may deliver requested records directly to Gemini Legal Support. Inc. (Evid. Code §1560(b)) or we can arrat'ige to copy or pickup tlie records at your location (Evid. Code (01560 (e)). Option 1: If Gemini is Copying or Picking up the records at )iour place of business, please contact our Expediting Depattment at (877) 739-7481 0pt. 1 or cqmpiete tlie bottom of tliis form and fax to (707) 204-6527. Option 2: If you would prefer to send records directly to Gemini, please return to us by: o Fax to (707) 204-6527 o Email to records(ageminiduplication.com o Mail to Gemini Legal Support, Inc., 6020 West Oaks Blvd, Suite 310, Rocklin, CA 95765 I would like Gemini to obtain records by (please select one):Pick Up (a copy will be made prior to pick up) Copy (Gemini will make a copy at your location) How many inches is the file? Our Pick Up/Copy Hours are: AppointrnentRequired: Yes € No € ' Mon.Tue.Wed.Thurs.Fri. Contaet Name: phpne Number: Please call tnuned+ately tf all pages are not received This fax is mtended ot'ily for tlie tise of CITY OF CUPERTINO CITY CLERK and may contain inforination tliat ts pnvtleged, confidenttal, artd exempt frotn disclosure under appltcablc law. If you are not the intended recipient, any dissemination, distributioi'i, or cop)ring oftliis cominuiucation is strictly prohibited. If you receive tlus communication ln elrOr, please notify us immediately by telephone and return the original fax to us at the above address You have been set-ved wtth a Subpoena Duces Tecum (subpoena foriecords) under tlie 3ui isdiction of tlie California WCAB (Cal Code Regs, tit 8 !)10530, Code Civ Proc §1985(c)) Thts subpoena fonnally cotnpels CITY OF CUPERTINO CITY CLERK to inake tlie requested recoids available for inspection and copying ui'idei reasonable condtOons dunng nonnal busmess hours (Evid Code §1560(e)) Failure to coi'nply may be puiushed as contempt by tlie court (Code Civ Proc §1991) Getnini Legal Support, Inc ts a professtonal photocopymg servtce (Bus & Prcf code, (i22450) and lias been assigned as deposition officer (Code Civ Proc § 1985 3 (a%3)) to compel and obtatn records for this inatter ' WO-1090761 REC-1108547 Records Subject: Ricardo Acevedo DateofBirth 1/1/199al SSN: DECLARATION OF CUSTODIAN OF RECORDS Name of records subject: Ricardo Acevedo I declare as follows pursuant to California Evidence Code sections 1560, 1561 : I am employed by and am the duly authorized custodian of records and am authorized to certify records for: CITY OF CUPERTINO-CITY CLERK (Faciliiy Name) Please be sure to include this Declaration along with the records you are providing to Gemini. Without a completed Declaration, this WCAB Subpoena for Records has not been fulfilled. If no records are being provided to Gemini, this Declaration is still required. I certify (Please check all that apply): OThat the accompanying records are true and complete copies of records described in the WCAB Subpoena for Records. These records were maintained in the regular Course and scope of business or the employer stated above and were prepared by authorized personnel. No records, documents or other materials have been withheld except as noted below. I further certify that I have made a diligent, thorough, and complete search of all available sources including the computer databases for both open and closed files whether in- house or in a storage facility or any other location under the control of my employer for any and all items to be produced on the attached subpoena duces tecum or authorization for records subject named above. OThat no records were produced because no records were found for the individual named on the subpoena duces tecum. Please indicate the reason, if any, as to why records do not exist: OThat partial records were produced. Please indicate below which records were not provided from those requested on the attached WCAB Subpoena for Records: 0That all or partial records are located at the following facility: Facility Name, Address, and Phone Number: Type of Records Located at this Facility 0That records Were provided to t'he Applicant Attorney of the Workers' Compensation CaSe stated On the provided subpoena duces tecum on (date). Records were produced in the following manner: gRecords were made available to Gemini and/or its affiliate for copying and/or picking up. gRecords were mailed/faxed/e-mailed to Gemini at the address listed on the WCAB Subpoena for Records in compliance with Evidence Code section 1 560 I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct and that this Declaration is executed on at (city), State of Printed name required Signature of custodian required iGEMINl 6.020 West Oaks Blvd, Suite 310 ' Rocklin, CA 95765 Phone (877) 739-7481 ' Fax (707) 204-6527 ST ATE OF' CALIFORNIA DEP ARTMENT OF INDUSTRLAL RE.LATIONS DIVISION OFWORKERSa COMPENSATION WORKF,RS' COMPENSATION APPEALS BOARD CaseNo ADJ17329936 Ricardo Aceved(i Claii'nant/Applicant, VS. City Of Cupertino/SEDGWICK CMS (IF APPLIC A'llON HAS BEEN FILED, CASE NUTV[BER MUST BE INDICATED REGARDLESS OF DATE OF INJURY) SUBPOENA DUCES TECUM (When records are mailed, identify them by using above cpse nutnber or attacl% a copy of subpoena) Wliere no application has been filed for injuries on or after Jaiiuary 1, 1990 and before January 1, 1994, subpoena will be v.alid without a case nuinber, but sribpoena must be served on claiinant alid employer and/or insurance carrier Employer/insurance Can ier/Defendant See instructions below " The People of the State of California Send Greetings !o: cxTY OF cupzppxrqo cxTY chppg TORRE AVE, IF - CUPERTINO, CA 95014 10300 We COMtS/fAND YOU to appear before: Gemini Leqal Support, Inc. at 6020 West Oaks Blvd, Suite 310, Rocklin, CA 95765 on the 19tb day of APrj-l r 2023 m 10 : o'clock .M.. to testify in t)ie above- entitled matter and to bring wit)i you and produce the following described documents, papers, books and records. -Please see Attachment 3 for detailed description of requested records- (Do not produce X-rays unless specifically menhoned above ) For failure to attend as reqriired, you may be deemed guilty of a contemyit and liable to pay to t)ie paities aggrieved all losses and damages sustained tliereby and foifeit one hundred dollars in addition thereto. This subpoena is issued at the request of the person making the declaratioii on the reverse liereof, or on the copy whicli is served herewitli. Date 3/28/2023 WORKERS' CONiPENSATION APPEALS BOARD OF THE STATE OF CALIFORNIA Secrelaiy, Assrslarit Secr'etary, Worker's' Compensalrori Judge %)4410a......a*a%-a%.-,a,a!0,,a.a.:a....a*a(aa...,. *FOR INJURIES OCCURING ON OR AFTER JANUARY 1, 1990, AND BEFORE JANUARY 1, 1994 If no Application for Adjudication of Claim l'ias been filed, a declaration under penalty of peijui'y that the Ei'nployee's Claim for Workers' Coinpensation Benefits (Form DWC-1) lias been filed pursuaiit to Labor Code Section 5401 i'nust be executed properly. SEE REVERSE SIDE (SUBPOENA JNVALID WITHOUT DECLARATION) You may fully comply with this subpoena by mailing the recoi ds desci ibed (or authenticated copies, Evid Code 1561) to the person and place stated above witlun ten (10) days of the date of service of tlus subpoena . Tliis subpoena does not apply to any inember of tlie Highway Patrol, Slieriffs Office oi cit' Police Departinent unless accoiiipai'iied by notice froin tl'iis Board that deposit of the witness fee has been inade in accordan'ce with Goveminent Code 68097 2, et seq DWC WCAB 32 (Side }) (REV 06/1 8)ReferenceNuinber WO'l090761 REC-1108547 DECLARATION FOR SUBPOENA DUCES TECUM CaseNumber: ADJ17329936 STATE OF CALIFORNIA, County of Santa Clara Tlie undersigned states: T)iat lie /slie is (one of) tlie attoi'ney(s) of record/ representative(s) for tlie applicant/defendant in tlie action captioned on t)ie reverse liereof. T)iat CITY OF CUPERTINO CITY CLERK l'ias in liis/her possession or under liis/)ier control the documents 4escribed 011 the reverse liereof. Tliat said documents are material to the issues involved in the case for the following reasons: SAID RECORDS ARE RELEVANT TO THE ALLEGATIONS AND DEFENSES BY THE PARTIES IN THE PROSECUTION OF THIS MATTER, TO PROVIDE AN ACCURATE MEDICAL HISTORY OF THE APPLICANT, TO PR0VE AN INJURY AND NOTICE THEREOF, TO PROVIDE THE RIGHT TO COMPENSATION, PERMANENT AND TEMPORARY DISABILITY, MEDICAL TREATMENT, AND ANY POSSIBLE PENALTIES. PURSUANT TO LABOR CODE SECTION 5401 FORM DWC 1 HAS BEEN DULY Fa:LED. Declaration for Injuries on or After January 1, 1990 and Before January 1, 1994 €Tliat an Employee's Claim for Workers' Compensation Benefits (DWC Form 1) lias been filed in accordance witli Labor Code Section 5401 by the alleged injured worker w)iose records are souglit, or if the worker is deceased, by tlie dependent(s) of the decedent, and that a true copy of tlie form filed is attached hereto. (Clieck box if applicable and part of declaration below. See instructions on fi'ont of subpoena.) I declare rinder penalty of perjury that the foregoing is true and correct Executed on 3 /28 /2023 , at San Jose CA 1660 Hamilton Ave Ste 202 /s/Tim English, Esq.San Jose, CA 95125 (408) 889-5598 Signature Address Telephone --Records being requested on behalf of WIESNER ENGLISH SAN JOSE-- DECLARATION OF SERVICE STATE OF CALIFORNIA, County of I, the undersigned, state that I served the foregoing subpoena by showing the origiiial and delivering a true copy thereof, together with a copy of the Declaration in support thereof, to each of the following named persons, personally, atthe date and place set forth opposite each name. Name of Person Served Date I declare under penalty of peijury that the foregoing is true and correct Executed on , at Signature DWC WCAB 32 (Side 2) (REV. 06/18)Reference Nuinber: 1090761 ATT ACHMENT 3 Case Name: Ricardo Acevedo vs. City Of Cupertino/SEDGWICK CMS Case Number: AD..H7329936 Records Subject: Ricardo Acevedo DateofBirth: 1/U1991 Records Requested: Any and all non-privileged physical and electronic personnel and wage records, including but not limited to application, reviews, warnings, write-ups, injury reports, medical records, doctors notes, earning statements, W-2's, workers compensation file, work schedule from beginning date of employment to present. All notices regarding the initiation of the employer's Medical Provider Network (MPN) both prior and subsequent to the date(s) of injury. All notices regarding the employer's Medical Network Provider, including all letters and notices to any party(ies) with all attachments, pamphlets, brochures and handouts. The employer's first report of injury form, the designation of a personal physician form, all evidence of every job-site posting of the employer related to workers' compensation claims and the employer's Medical Provider Network. All documents signed by the applicant, the insurance repyesentative or the employer verifying receipt of any of the above documentation. Records pertain to Ricardo Acevedo 7 DOB: 1/1/1991 Ref#: WO-1090761 REC-1108547 Ref#:WO-1090761 REC-1108547 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, stake bar number, and address) Tim English, Esq. 292951 WIESNER ENGLSH SAN JOSE 1660 Hamilton Ave Ste 202 San JOSe CA 95125 EmailAdtlress(optional) TELEPHONE NO ( 4 0 8 ) 8 8 9- 5 5 9 8 FAX NO. " ATTORNEYFOR(Name) RiCardO ACeVed0 For Cr>urt Use Only San Jose District Officea ' "100 Paseo de San Antonio, Suite 24"l San Jose, CA 95113-1402 PLAINTIFF/PETITIONER: Ricardo Acevedo DEFENDANT/RESPONDENT City Of Cupertino/SEDGWICK CMS CASE NU-MBER'-----' - ADJ17329936I NOTICE TO CONSUMER OR EMPLOYEE 70(yl3l-11B); Ricardo Acevedo and interested parties 1. PLEASE TAKE NOTICE THAT REQUESTING PARTY (name):Ricardo Acevedo Wed, Apr 19, 2023SEEKS YOUR RECORDS FOR EXAMINATION by the parties to this action on (s;pecify date): The records are described in the subpoena directed to witness (specify name and address of entity from whom records are sought): CITY OF CUPERTINO CITY CLERK 10300 TORRE AVE, IF CUPERTINO CA 95014 A copy of the subpoena is attached. 2. IF YOU OBJECT to the production ofthese records, YOU MUST DO ONE OF THE FOLLOWING BEFORE THE DATE SPECIFIE IN ITEM a. OR b. BELOW: a. IF you are a parky to the above-entitled action, you must file a motion pursuant to Code of Civil Procedure section 1987.1 to quash or modify the subpoena and give notice of that motion to the witness and the deposition officer named in the subpoena at least five days before the date set for production of the records. b. If you are not a party to this action, you must serve on the requesting paity and on the witness, before the date set for production of the records, a written objection that states the specific grounds on which production of such records should be prohibited. You may use the form below to object and state the grounds for your objection. You must complete the proof of service on the reverse side indicating whether you persorially served or mailed the objection. The objection should not be filed with the court. WARNING: IF YOUR OBJECTION IS NOT RECEIVED BEFORE THE DATE SPECIFIED IN ITEM 1, YOUR RECORDS MAY BE PRODUCED AND MAY BE AVAILABLE TO ALL PARTIES. 3. YOU OR YOUR ATTORNEY MAY CONTACT THE UNDERSIGNED to determine whether an agreement can be reached in writing to cancel or limit the scope of the subpoena. If no such agreement is reached, and if you are not otherwise represented by an attorney in this action, YOU SHOULD CONSULT AN ATTORNEY TO ADVISE YOU OF YOUR RIGHTS OF PRIVACY. Date: 3/28/2023 Tim English, Esq. (TYPE OR PRINT NAME) /s/Tim English, Esq. (SIGNATURE OF € REQUESTING PARTY [J ATTORNEY) OBJECTION BY NON-PARTY TO PRODUCTION OF RECORDS 'i. @ i object to the production of all of my records specified in the subpoena. :. @ I object to the production of the following specified records: 3. The specific grounds for my objection are as follows. Date: (TYPE OR PRINT NAME) see following for proof o[ service NOTICE TO CONSUMER OR EMPLOYEE AND OBJECTION (Code Civ. Proc., '1985.3, 1985.6) (SIGNATURE) SUBP-025 PLAINTIFF /PETITIONER: Ricardo Acevedo DEFENDANT/RESPONDENT: City Of Cqper'_jr+o;SEDGTtT:i:CK CMT, Case Number AD,J17329936 PROOF OF SERVICE OF NOTICE TO CONSUMER OR EMPLOYEE AND OBJECTION P(eCrosdOenaClivs.e:rolcce., "la985.3,Mla9.l815.jlX 1. At the-time of service, I was at least 18 years of age and not a party to this legal action. 2, I served a copy of the Notice to Consumer or Employee and Objegtion as follows (check either a or b) a. [1] Personal Service. I personally delivered the Notice to Consume7 or Employee and Objection as follows: (1 ) Name of person served: (2) Address where served: (3) Date Served: (4) Time Served' with postage fully prepaid. The envelope was addressed as follows: (1) Name of person served Tim Englishi Esq (2) AddreSS where Served: 1660 Hamilton Ave Ste 202 (3) Date Served: 3/28/2023 (4) Place of Mailing (city and state'): (3) Date Served: 3/28/2023 (4) Place of Mailing (city and state): San Jose, CA 95125 Rocklin, California (5) I am a resident of or am employed in the ccunty uihere'the Notice to Consumer or Employee and Objection was mailed. c. Myresidenceorbusinessaddressis(specify): 6020 west Oaks Blvdi Suite 310, Rocklin, CA 95765 d. Myphonenumberis(specify): (877) 739-7481 I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: 3/28/2023 "':" "/a"'(<:f""J' V/'-,,, (, )r-z.->qjl)?l/, \,,-' Steven Dolphin (WP(: 5R'l:'R'lNT' NAtQE 5F at'Ef'iS5t'lalM'l6 SERVe5)" a - :" -a a " - : a ' a " o (SIGNATURE OF PERSON WHO SERVED) PROOF OF SERVICE OF OBJECT!ON TO PRODUCTION OF RECORDS 1. At the time of service, I was at least 18 years of ae and not a party to this legal action. 2. I served a copy of the Notice to Consumer or Emplriyee ana Objectiari as follows (complete either a or b) a. ON THE REQUESTING PARTY (1 ) Personal service. I personally delivered the Objer,h@n to Production of Records as follows: (i.) Name of person served: (iii.) Date Served: (ii.) Address where served: (iv.) Time Served: (2) B Mail. I deposited the Objection to Produgtion ot Records in the United States mail, in a sealed envelope with postage fully prepaid. The envelope was addressed as follows: (i.) Name of person served: ' (iii.) Date of mailing: (ii.) Address: (iv.) Place of mailing (city and state (v.) I am a resident of or am employed in the cuanty'vvhere the Objection to Production of Records was mailed. b. ON THE WITNESS (1 ) [1] Personal seivice. I personally delivered the Objection to Pr'oductron of Records as follows: (i.) Name of person served: (iii.) Date Served: (ii.) Address where served: (iv.) Time Served: (2) Mail. I deposited the Objection to Proiju.c!i(irl of Ret,ords in the United States mail, in a sealed envelope with postage fully prepaid. The envelope was add'e%ed as follows: (i.) Name of person served:(iii.) Date of mailing: (ii.) Address: (iv.) Place of mailing (city and state): (v. ) I am a resident of or am employed iri trie coiinty where the Objection to Production of Records was mailed. 3. My residence or business address is (specify).' 4. My phone number is (specify): " I declare under penalty of pe2ury under the laws of the 5tate cf Ca!:fornia that the foregoing is true and correct. Date: (TYPE OR PRINT NAME OF PERSON WHO SERVED) SIGNATUj 0F !!Yl-10 SERVED) NOTICE TO CONSIIMER OR EMPLOYEE AND OBJECTIONSLIBP-025[Rev. Januaiy 1, 2008]Page two Case No.: ADJ17329936 Case Name: Ricardo Acevedo v. City Of Cupertino/SEDGWICK CMS Proof of Service I am employed in the county of Placer. lam over the age of eighteen years and not a party to the entitled action. My business address is 6020 West: Oaks Blvd, Suite 310, Rocklin, CA 95765. On 3/28/2023, I served the Foregoing documents described as WCAB Subpoena, Attachment 3, Notice to Consumer on each interested party in,this action by placing a true copy thereof enclosed in a sealed envelope and addressed as follows: Delivered to Tim English, Esq.WIESNER ENGLI!7H SAN, JOSE Address 1660 Hamilton Ave Ste 202 San Jose, CA 95125 Method Mail SEDGWICK CMS SEDGWICK CMS Pa BOX 14433 LEXINGTON, KY 40512 Mail RTGR LAW OAKLAND RTGR LAW OAKLAND 180 Grand Ave Ste 300 Oakland, CA 94612 Mail I am "readily familiar" with this firm's practice of collection and processing correspondence. Under that practice, it will be delivered, same day, via digital delivery to our vendor DocuCents who will deposit it with the u.s. Postal Service on the same day with postage thereon Fully prepaid in Covina, California, in the ordinary course of business. I declare under the penalty of perjury under the laws of the State of California that the foregoing is true and correct. Executed on 3/28/2023, at Rocklin, California. 6"11,,)(,trvDd'fa'v Steven Dolphin !1, MichaerSanchez 52Cll GemtniLegal ' 1 = go-'tsffisaaz i s_ s_ '% - ' ) - i%a-a s> y 60!_O West Oaks Blyd., Suite 3j 0 sochitn,CA95785 2fl _ I al i I .. - " IPOarXefron'hfe' CXX 'l'x Q C" ""k'C'o C%"y C\""S $ \'5 A" a:,'!li iI ----- '-- - ' nn'll.Tq .E,.-I ! !,iJsaPcMraomregna1on cCA:tiase Bank, N.A. i Fo'r "y('=%os\s $ i! l -0='-;'%-l;"o':-'-""'l-"-'-""""""'-l-'-"-''-""-'-"-'"l:3????if.??l: ?!giSR €i?]