The claimant agreed to allow me to withdraw from representation as indicated in Part I above.OC-400.17 (1-18)Pursuant to 12 NYCRR 247 300.17, this form must be submitted whenever an attorney or licensed representative seeks to withdraw his or her representation of a claimant before the Board or a Workers' Compensation Law Judge in any claim or claims. Send this form to the claimant and secure the claimant's signature in Part I. Complete Part II and check the appropriate box in Part II, Section C., hereby request to withdraw from representation of the above A. I,named claimant in the cases listed above. My request to withdraw meets the standards set forth in 12 NYCRR 247 300.17, and the Rules of Professional Conduct for attorneys (22 NYCRR 1200.16 Rule 1.16) or the Rules of Conduct for licensed representatives (12 NYCRR 302-2) and is based on the following reason(s): WCB Case #(s) Claimant's Name (Last, First, MI) Claimant Name (Last, First, MI) Signature of Claimant PO Box 5205, Binghamton, NY 13902-5205 Web Upload link: https://wcbdoc.services.conduent.com/ATTORNEY/LICENSED REPRESENTATIVE REQUEST TO WITHDRAW FROM REPRESENTATIONB. Check all applicable boxes: 1.Check ONE of the following: There is no application for review pending before the Board or the Full Board or an appeal to the Appellate Division; A hearing is not scheduled in this matter and I have not been notified of any other deadline that requires a response; A hearing is set for the date of: A deadline for a response to has been set for the dateD. I certify that the above is true and correct to the best of my knowledge. I have today served a copy of this request on all parties, their representatives, and unrepresented parties in this claim, including the claimant. Signature of Attorney/Licensed Representative Address of Attorney/Licensed Representative Attorney/Licensed Representative Phone Number Date Submittedwww.wcb.ny.gov l THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. R-Attorney/Licensed Representative's Identification Number (if any) Part I I am the claimant in this matter/these matters. I agree to allow my attorney/licensed representative to withdraw from representing me in the above listed case(s). Part II The claimant has not been classified (see Subject Number 046-548, May 28, 2013). The following cases(s) have been settled via Section 32 waiver agreement (list all claims settled via Section 32): C. Check ONE of the following: I attempted in good faith to secure the claimant's signature in Part I above. There is an appeal pending before , and a response is due2.Check ONE of the following:3. 4. 5. American LegalNet, Inc. www.FormsWorkFlow.com