NHJB-2391-DF (03/25/2013) Page 1 of 1 THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) APPEARANCE/WITHDRAWAL APPEARANCE WITHDRAWAL Please enter my appearance as Please withdraw my appearance as Counsel for Counsel for I will represent myself (pro se). Notice of Withdrawal sent to my clients on: at the following address: I certify that on this date I provided a copy of this document to party(s) listed below by: Hand-delivery US Mail Email (E-mail only by prior agreement of the parties based on Circuit Court Administrative Order) Name Address Date Signature Printed Name Mailing Address Telephone NH Bar ID # Email Address (optional) American LegalNet, Inc. www.FormsWorkFlow.com