FORM 93 Send original and 2 copies to Court of Existing Claims In re claim of: Full Name of Claimant (Injured Employee) COURT OF EXISTING CLAIMS 1915 NORTH STILES, STE 127 OKLAHOMA CITY, OKLAHOMA 73105-4918 THIS SPACE FOR COURT USE ONLY Claimant's Social Security Number (LAST 4 DIGITS ONLY) XXX-XX-___________________________ Name of Employer (Respondent) Employer's Insurance Carrier, Permit # for Court Approved Individual Self-Insured or Own Risk Group, Uninsured APPLICATION AND ORDER FOR LEAVE TO WITHDRAW AS ATTORNEY OF RECORD WCC FILE NO. Date of injury COMES NOW the undersigned Attorney of Record in the above-captioned matter and requests this Court for leave to withdraw as Attorney of Record pursuant to Court of Existing Claims Rule 51, and in support thereof states: YES ________ ________ ________ ________ ________ ________ ________ ________ NO ________ ________ ________ ________ ________ ________ ________ ________ Please mark the appropriate yes/no response to the left of each numbered question. 1. 2. 3. 4. 5. 6. 7. 8. The client has knowledge of this Application To Withdraw as Attorney. The client has approved the withdrawal. I have made a good faith effort to notify the client and the client cannot be located. The case is set for: Trial TID PHC Mediation Date of Proceeding: ___________________ On the Issue(s) ______________________________________ The case has been tried and is pending for an Order. TRIAL DATE: ________________________ On the Issue(s) of: ___________________________________ The case is pending, on appeal to the : Court En Banc Supreme Court An Order awarding Permanent Total Disability has been entered by the Court. DATE OF ORDER: _______________________________________________________________________ An Order awarding Death Benefits has been entered by the Court. DATE OF ORDER: _______________________________________________________________________ I declare under penalty of perjury that I have examined all statements contained herein, and to the best of my knowledge and belief, they are true, correct and complete. Any person who commits workers' compensation fraud, upon conviction, shall be guilty of a felony. I HEREBY CERTIFY THAT A COPY HAS BEEN SENT TO: Opposing Party Address (Number & Street) City State Zip Code Signed this_______day of____________________,______ Signature of Requesting Party Address (Number & Street) City State Zip Code Withdrawing Attorney's Client Address (Number & Street) City State Zip Code Telephone # of Requesting Party Print or type name of Attorney OBA # IT IS THEREFORE ORDERED, for good cause shown, that the above signed attorney is hereby permitted to withdraw as Attorney of Record from the above captioned case. BY ORDER OF _______________________________________________________ _______________________ Rev. 06/24/2015 American LegalNet, Inc. www.FormsWorkFlow.com Date of Order