REQUEST TO WITHDRAW APPEAL

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					                                             STATE OF TENNESSEE
                              DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
                                        Division of Employment Security
                                               Appeals Operations
                                            220 French Landing Drive
                                         Nashville, Tennessee 37243-1002

                                                    Telephone: (615) 741-1857
                                                    Facsimile: (615) 741-8933



                                         REQUEST TO WITHDRAW APPEAL



    Claimant’s Social Security Number ______________________            Docket Number _____________________



Claimant’s Name _____________________________________             Employer’s Name ______________________________________


Street Address ______________________________________             Street Address _______________________________________


City _____________________ State ____ Zip ______________          City ______________________ State ____ Zip ______________


Claimant’s Telephone ______________________________               Employer’s Telephone ________________________________




I am the:     claimant                employer


Please withdraw my appeal.

(optional) I do not wish to pursue this appeal further because




Date ___________________                         Signature _________________________________________

                                                 Title (if employer) __________________________________________________


LB-0894 (Rev. 04-11)                                                                                            RDA 1643

				
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