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Application And Order For Leave To Withdraw As Attorney Of Record CC-Form-93 - Oklahoma

Application And Order For Leave To Withdraw As Attorney Of Record Form. This is a Oklahoma form and can be used in Workers Comp .
 Fillable pdf Last Modified 3/18/2014
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CC-FORM-93 Send original and 2 copies to: or ers o pensa on o ission WORKERS' COMPENSATION COMMISSION 1915 NORTH STILES AVENUE OKLAHOMA ITY, OKLAHOMA 73105 THIS SPA E FOR OMMISSION USE ONLY In re claim of: Full Na e of lai ant (Injured E ployee) lai ant s Social Security Nu ber (LAST 4 DIGITS ONLY) XXX-XX-___________________________ APPLICATION AND ORDER FOR LEAVE TO WITHDRAW AS ATTORNEY OF RECORD COMMISSION FILE NO. Na e of E ployer (Respondent) E ployer s Insurance arrier, Per it # for o Ris Group, Uninsured ission Approved Individual Self-Insured or Own Date of injury OMES NO t e undersigned A orney of Record in t e above-cap oned a er and re uests t e o ission for leave to wit draw as A orney of Record pursuant to or ers o pensa on o ission Rule 10:2-1-10(c), and in support t ereof states: YES ________ ________ ________ ________ NO ________ ________ ________ ________ Please ar t e appropriate yes no response to t e le of eac nu bered ues on 1 2 3 4 ________ ________ 5 ________ ________ ________ ________ ________ ________ 6 7 T e client as nowledge of t is T e client as approved t e wit drawal I ave ade a good fait e ort to no fy t e client and t e client cannot be located T e case is set for: Hearing PH Media on Date of Proceeding: _________________________ On t e Issue(s) ________________________________ _______________________________________________________________________________________ T e case as been eard and is pending for an Order HEARING DATE: ________________________ On t e Issue(s) of: __________________________________ _______________________________________________________________________________________ T e case is pending on appeal to t e : o ission En Banc Supre e ourt An Order awarding Per anent Total Disability as been entered by t e o ission DATE OF ORDER: _________________________________________________________________________ An Order awarding Deat Benefits as been entered by t e o ission DATE OF ORDER: _________________________________________________________________________ I declare under PENALTY OF PERJURY t at I ave examined all statements contained erein, and to t e best of my kno ledge and belief, t ey are true, correct and complete. Any person o commits orkers' compensa on fraud, upon convic on, s all be guilty of a felony punis able by imprisonment, a fine or bot . I HEREBY CERTIFY THAT A COPY HAS BEEN SENT TO: Opposing Party Signed t is _____ day of __________________________,______ Signature of Re ues ng Party Address (Number & Street) City State Zip Code Address (Number & Street) Wit dra ing A orney's Client City State Zip Code Address (Number & Street) Telep one of Re ues ng Party City State Zip Code Print or type name of A orney OBA IT IS THEREFORE ORDERED, for good cause s own, t at t e above signed a orney is ereby per i ed to wit draw as A orney of Record fro t e above cap oned case BY ORDER OF _______________________________________________________ ____________________________________ Date of Order Created 2-1-14 American LegalNet, Inc. www.FormsWorkFlow.com
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