Last updated: 8/18/2011
Attorney Leave Of Absence {WC-102C}
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Description
WC-102c ATTORNEY LEAVE OF ABSENCE GEORGIA STATE BOARD OF WORKERS' COMPENSATION ATTORNEY LEAVE OF ABSENCE Complete this form, and send I, Address -1299 City Attorney E-mail State Zip Code GA Bar Number Do hereby request that I be granted a leave of absence on cases in which I am counsel of record for the following period(s) of time: / (month) (day) / (year) through (month) / (day) / (year) / (month) (day) / (year) through (month) / (day) / (year) / (month) (day) / (year) through (month) / (day) / (year) IF YOU HAVE QUESTIONS PLEASE CONTACT TH -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-102c REVISION . 07/2011 102c ATTORNEY LEAVE OF ABSENCE American LegalNet, Inc. www.FormsWorkFlow.com
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