Form #A-17a

Board or State Association

Address

City

State

Zip

Notice of Settlement, Withdrawal of Arbitration Request

Notice is given herewith to the ______________________ (Board or State Association) that in the matter of
_________________________ vs. _________________________ the parties have reached a settlement, the parties have satisfied
the terms of the settlement agreement, and the arbitration request in the matter of _________________________ vs.
_________________________ is hereby withdrawn by the complainant(s).

Complainant Name (Type/Print)

Signature

Date

Complainant Name (Type/Print)

Signature

Date

*NOTE: This form, or one substantively similar, may be required by associations when complainants wish to withdraw their
arbitration requests after settlement.
(Adopted 5/16)