Request Form For Leave To Withdraw As Counsel

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FIRST JUDICIAL DISTRICT OF PENNSYLVANIA
PHILADELPHIA MUNICIPAL COURT
TRAFFIC DIVISION
Commonwealth of Pennsylvania
Citation No(s).
vs.
_____________________________
Defendant’s Name
REQUEST FOR LEAVE TO WITHDRAW AS COUNSEL
Defendant’s Name
OLN
Address
City
State
Zip
Name of Defendant’s Attorney
Attorney ID #
Office Address
City
State
Zip
Electronic Mail Address of Attorney:
Date of Trial
Time
Courtroom (If Available)
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
Date
ORDER
Counsel’s request to withdraw as counsel for the Defendant is:
Granted. Reason:
Denied. Reason:
BY THE COURT:
Date: ______________
_____________________________________________
MUNICIPAL COURT JUDGE
02-63 (Rev. 7/13)

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