Attorney Withdrawal Lien {WC-108b}

WC-108b GEORGIA STATE BOARD OF WORKERS' COMPENSATION ATTORNEY WITHDRAWAL / LIEN Employee Last Name Employee First Name M.I. SSN or Board Tracking # ATTORNEY WITHDRAWAL / LIEN Board Claim No. Date of Injury A. NOTIFICATION TO CLIENT I hereby notify (Client) that I am withdrawing from representation in this claim. I certify that there is no review pending before the Appellate Division. A hearing / mediation is not scheduled in this matter and I have not been notified of any other deadline which requires a response. A hearing / mediation has been scheduled / / , and a notice is attached. for the date of (month) (day) (year) A deadline for a response to has been set for the date of (month) / (day) / (year) . jurisdiction of this case and that the failure or refusal to meet your legal obligations with respect to your claim may result in penalties and / or loss of benefits. If you have any further questions, you may contact the ion at 1-800-533-0682 or 404-656-3818. In writing, I withdrew from representation on the date of (month) / (day) / (year) . I received in writing on (month) / (day) / (year) that my client terminated my services. (Copy attached) (Attach supporting documentation or the lien will not be approved.) I certify the fair and reasonable value of my services is $ The following actual and reasonable expenses have been incurred in this claim: (List specific expense.) C. CERTIFICATE OF SERVICE I hereby certify that the above is true and correct to the best of my knowledge. unrepresented parties in this claim, including my former client. Print Name Here I have today served a copy of this on all counsel and Phone Number and Ext Signature Address Date E-mail City State Zip Code GA Bar Number -656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. §34-9-18 AND §34-9-19). WC-108b REVISION . 07/2011 108b ATTORNEY WITHDRAWAL / LIEN American LegalNet, Inc. www.FormsWorkFlow.com