ILLINOIS WORKERS' COMPENSATION COMMISSION MOTION TO WITHDRAW AS ATTORNEY OF RECORD
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Employee/Petitioner v.
Case # ________ WC ____________________
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Employer/Respondent
I, ______________________________________________ , attorney for the petitioner ____ respondent ____ , request permission to withdraw as the attorney of record on this case for the following reason:
_____________________________________________ Signature of attorney
_____________________________________________ Name of attorney and IC code number (please print)
_____________________________________________ Date
IC28 12/04 100 W. Randolph St. #8-200 Chicago, IL 60601 312/814-611 Toll-free 866/352-3033 Web site: www.iwcc.il.gov Downstate offices: Collinsville 618/346-3450 Peoria 309/671-3019 Rockford 815/987-7292 Springfield 217/785-7084