Withdrawal Request Form, Form 43

• Legal Form Number: 43
• Section: Office of Congressional Workplace Rights (United States)

advancing workplace rights, safety and health, and accessibility in the legislative branch

Officeof CongressionalWorkplaceRights

OCWR Form 43 – Revised 7/2022

Room LA-200, John Adams Building · 110 Second Street, SE · Washington, DC 20540-1999 · t/202.724.9250 · f/202.426.1913

www.ocwr.gov

LABOR MANAGEMENT – WITHDRAWAL REQUEST FORM

Completed forms may be e-mailed toLMR@ocwr.gov; mailed or dropped off to Room LA-200, John Adams

Building, 110 Second Street SE, Washington, DC 20540-1999; or faxed to (202) 426-1913.

Re: __________________________________________

(Name of Employing Office)

Case No. ________________________________________

This is to request withdrawal of the above-named case.

_________________________________________________________

(Name of Party Filing)

By _________________________________________________________

(Name of Representative)

_________________________________________________________

(Signature)

_________________________________________________________

(Date)

WITHDRAWAL REQUEST APPROVED.

Office of Congressional Workplace Rights

_________________________________________

Executive Director

Dated: ___________________________________