FIRST JUDICIAL DISTRICT OF PENNSYLVANIA PHILADELPHIA MUNICIPAL COURT TRAFFIC DIVISION Commonwealth of Pennsylvania vs. _____________________________ Defendant's Name REQUEST FOR LEAVE TO WITHDRAW AS COUNSEL Defendant's Name Address City State OLN Zip Citation No(s). Name of Defendant's Attorney Office Address Electronic Mail Address of Attorney: Date of Trial Time Courtroom (If Available) City State Attorney ID # Zip Reason for Request to Withdraw (Attach all necessary documentation) Defendant's Position I verify that the statements made herein are true and correct, and that false statements herein are made subject to the penalties of 18 Pa.C.S. �4904, relating to unsworn falsification to authorities. _____________________________________________ Signature of Attorney ORDER Counsel's request to withdraw as counsel for the Defendant is: Granted. Reason: Denied. Reason: BY THE COURT: ___________________ Date Date: ______________ _____________________________________________ MUNICIPAL COURT JUDGE 02-63 (Rev. 7/13) American LegalNet, Inc. www.FormsWorkFlow.com