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Attorney Withdrawal Lien Form. This is a Georgia form and can be use in Workers Comp.
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Tags: Attorney Withdrawal Lien, WC-108b, Georgia Workers Comp,
WC-108b
ATTORNEY WITHDRAWAL / LIEN
GEORGIA STATE BOARD OF WORKERS' COMPENSATION
ATTORNEY WITHDRAWAL / LIEN
Board Claim No.
Employee Last Name
Employee First Name
M.I.
SSN or Board Tracking #
Date of Injury
A. NOTIFICATION TO CLIENT
I hereby notify
(Client) that I am withdrawing from representation in this claim.
I certify that there is no review pending before the Appellate Division.
A hearing / mediation is not scheduled in this matter and I have not been notified of any other deadline which requires a response.
A hearing / mediation has been scheduled
/
/
, and a notice is attached.
for the date of
(month)
A deadline for a response to
(day)
(year)
/
has been set for the date of
/
(month)
(day)
.
(year)
jurisdiction of this case and that the failure or refusal to meet your
legal obligations with respect to your claim may result in penalties and / or loss of benefits. If you have any further questions, you may contact the
ion at 1-800-533-0682 or 404-656-3818.
/
In writing, I withdrew from representation on the date of
(month)
/
I received in writing on
/
(month)
(day)
/
.
(day)
(year)
that my client terminated my services. (Copy attached)
(year)
I certify the fair and reasonable value of my services is $
(Attach supporting documentation or the lien will not be approved.)
The following actual and reasonable expenses have been incurred in this claim: (List specific expense.)
C. CERTIFICATE OF SERVICE
I hereby certify that the above is true and correct to the best of my knowledge.
unrepresented parties in this claim, including my former client.
I have today served a copy of this on all counsel and
Print Name Here
Phone Number and Ext
Signature
Address
E-mail
Date
City
State
Zip Code
GA Bar Number
-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-108b
REVISION . 07/2011
108b
ATTORNEY WITHDRAWAL / LIEN
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