Form 93 - Application And Order For Leave To Withdraw As Attorney Of Record
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1COURT OF EXISTING CLAIMS
THIS SPACE FOR COURT USE ONLY
1915 NORTH STILES, STE 127
FORM 93
OKLAHOMA CITY, OKLAHOMA 73105-4918
Send original and 2 copies to
Court of Existing Claims
In re claim of:
Full Name of Claimant (Injured Employee)
Claimant’s Social Security Number (LAST 4 DIGITS ONLY)
APPLICATION AND ORDER FOR LEAVE TO WITHDRAW
XXX-XX-___________________________
AS ATTORNEY OF RECORD
WCC FILE NO.
Name of Employer (Respondent)
Employer’s Insurance Carrier, Permit # for Court Approved Individual Self-Insured or Own
Date of injury
Risk Group, Uninsured
COMES NOW the undersigned Attorney of Record in the above-captioned matter and requests this Court for leave to withdraw
as Attorney of Record pursuant to Court of Existing Claims Rule 51, and in support thereof states:
NO
YES
Please mark the appropriate yes/no response to the left of each numbered question.
________
________
1.
The client has knowledge of this Application To Withdraw as Attorney.
________
________
2.
The client has approved the withdrawal.
________
________
3.
I have made a good faith effort to notify the client and the client cannot be located.
________
________
4.
The case is set for:
Trial
TID
PHC
Mediation
Date of Proceeding: ___________________ On the Issue(s) ______________________________________
________
________
5.
The case has been tried and is pending for an Order.
TRIAL DATE: ________________________ On the Issue(s) of: ___________________________________
________
________
6.
The case is pending, on appeal to the :
Court En Banc
Supreme Court
________
________
7.
An Order awarding Permanent Total Disability has been entered by the Court.
DATE OF ORDER: _______________________________________________________________________
________
________
8.
An Order awarding Death Benefits has been entered by the Court.
DATE OF ORDER: _______________________________________________________________________
I declare under penalty of perjury that I have examined all statements contained herein, and to the best of my knowledge and belief, they are true,
correct and complete. Any person who commits workers’ compensation fraud, upon conviction, shall be guilty of a felony.
I HEREBY CERTIFY THAT A COPY HAS BEEN SENT TO:
Opposing Party
Signed this_______day of____________________,______
Signature of Requesting Party
Address (Number & Street)
Address (Number & Street)
City
State
Zip Code
Withdrawing Attorney’s Client
City
State
Zip Code
Address (Number & Street)
Telephone # of Requesting Party
City
State
Zip Code
Print or type name of Attorney
OBA #
IT IS THEREFORE ORDERED, for good cause shown, that the above signed attorney is hereby permitted to withdraw as
Attorney of Record from the above captioned case.
BY ORDER OF _______________________________________________________ _______________________
Date of Order
Rev. 06/24/2015
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Parent category: Legal