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FIRST JUDICIAL DISTRICT OF PENNSYLVANIA PHILADELPHIA MUNICIPAL COURT TRAFFIC DIVISION Commonwealth of Pennsylvania vs. _____________________________ Defendant's Name REQUEST FOR LEAVE TO WITHDRAW AS COUNSEL Defendant's Name Address City State OLN Zip Citation No(s). Name of Defendant's Attorney Office Address Electronic Mail Address of Attorney: Date of Trial Time Courtroom (If Available) City State Attorney ID # Zip Reason for Request to Withdraw (Attach all necessary documentation) Defendant's Position I verify that the statements made herein are true and correct, and that false statements herein are made subject to the penalties of 18 Pa.C.S. §4904, relating to unsworn falsification to authorities. _____________________________________________ Signature of Attorney ORDER Counsel's request to withdraw as counsel for the Defendant is: Granted. Reason: Denied. Reason: BY THE COURT: ___________________ Date Date: ______________ _____________________________________________ MUNICIPAL COURT JUDGE 02-63 (Rev. 7/13) American LegalNet, Inc. www.FormsWorkFlow.com