Free Form 93.pub - Oklahoma

FORM 93
Send original and 3 copies to Workers' Compensation Court

WORKERS' COMPENSATION COURT 1915 NORTH STILES OKLAHOMA CITY, OKLAHOMA 73105-4918

THIS SPACE FOR COURT USE ONLY

In re claim of: Full Name of Claimant (Injured Employee)

Claimant's Social Security Number

APPLICATION AND ORDER FOR LEAVE TO WITHDRAW AS ATTORNEY OF RECORD
FILE NO. Date of injury

Name of Employer or Respondent Employer's Insurance Carrier, Permit # for Court Approved Individual Self-Insured or Own Risk Group, Uninsured

COMES NOW the below signed Attorney of Record in the above-captioned matter requests that this Court grant leave to withdraw as Attorney of Record pursuant to Workers' Compensation Court Rule 51. In support of this Application, the undersigned attorney states as follows:

YES
________ ________ ________ ________ ________ ________ ________ ________

NO
________ ________ ________ ________ ________ ________ ________ ________

Please mark the appropriate yes/no response to the left of each numbered question.
1. 2. 3. 4. 5. 6. 7. 8. The client has knowledge of this Application To Withdraw as Attorney. The client has approved the withdrawal. I have made a good faith effort to notify the client and the client cannot be located. The case is set for: Trial TID PHC Settlement Conference Mediation Date of Proceeding: ___________________ On the Issue(s) ______________________________________ The case has been tried and is pending for an Order. TRIAL DATE: ________________________ On the Issue(s) of: ___________________________________ The case is pending, on appeal to the : Court En Banc Supreme Court An Order awarding Permanent Total Disability has been entered by the Court. DATE OF ORDER: _______________________________________________________________________ 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 Address (Number & Street) City State Zip Code

Signed this________________day of___________,______
Signature of Requesting Party Address (Number & Street) City State Zip Code

Withdrawing Attorney's Client Address (Number & Street) City State Zip Code

Telephone # of Requesting Party 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 _________________________________________________________ _____________________
2/06

Date of Order