WC-102c ATTORNEY LEAVE OF ABSENCE GEORGIA STATE BOARD OF WORKERS' COMPENSATION ATTORNEY LEAVE OF ABSENCE Complete this form, and send -1299 I, Address City State Zip Code Attorney E-mail 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) / (month) / (day) / (month) (month) (month) (month) IF YOU HAVE QUESTIONS PLEASE CONTACT TH (year) / (day) / through (year) / (day) / through (year) / (day) / through (year) (year) / (day) (year) -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