Free lb0894AppealsNewAddress.pmd - Tennessee


File Size: 41.1 kB
Pages: 1
Date: December 28, 2007
File Format: PDF
State: Tennessee
Category: Workers Compensation
Author: CC30218
Word Count: 83 Words, 1,422 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.state.tn.us/labor-wfd/Appeals/forms/LB-0894.pdf

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STATE OF TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Employment Security Appeals Operations 220 French Landing Drive Nashville, Tennessee 37243
Telephone: (615) 741-1857 Facsimile: (615) 741-8933

Request to Withdraw Appeal

Claimant's Social Security Number ____________________________

Docket Number ___________________________

Claimant's Name __________________________________

Employer's Name ____________________________________

Street Address ____________________________________

Street Address ______________________________________

City _____________________ State ____ Zip ___________

City ______________________ State ____ Zip ____________

Claimant's Telephone ______________________________

Employer's Telephone ________________________________

I am the:

claimant

employer.

Please withdraw my appeal. I do not wish to pursue this appeal further because ___________________________________

_________________________________________________________________________________________________________ (optional) _________________________________________________________________________________________________________

_________________________________________________________________________________________________________

Date _______________________

Signature ______________________________________ Title ___________________________________________ (if employer)

LB-0894