Annexation Arbiter Emergency Withdrawal (To Be Submitted by an Arbiter to Panel Chair, if one has been elected, and DCA, In Case of Need)
I. Attestation
I, Type Arbiter's Name Here, a trained volunteer arbitration panelist, having previously confirmed my availability to serve on an arbitration panel, do hereby attest to my inability to continue my service on the panel to which I was appointed due to unforeseen circumstances, between the dates of: Type Date Range of Inavailability, Or, for the entire remaining period of this panel’s appointment.
II. Consent for Appointment to Future Panels (Mark the Box Next to the Response You Choose.)
I give my consent to the Georgia Department of Community Affairs to submit my name and appoint me to future annexation arbitration panels. OR I withdraw my consent to the Georgia Department of Community Affairs to submit my name and appoint me to future annexation arbitration panels.
III. Signature
Signed:	Date:
Send this form to: Georgia Department of Community Affairs Office of Planning (Annexation Arbitration) 60 Executive Park South, NE Atlanta, Georgia 30329 Email: planning@dca.ga.gov

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