diff --git a/.github/ISSUE_TEMPLATE/remove-maintainer b/.github/ISSUE_TEMPLATE/remove-maintainer
new file mode 100644
index 0000000..dbba2f7
--- /dev/null
+++ b/.github/ISSUE_TEMPLATE/remove-maintainer
@@ -0,0 +1,30 @@
+---
+name: Maintainer Removal Request
+about: Request removal as maintainer from one or more Dapr repositories
+title: 'REQUEST: Remove as maintainer <your-GH-handle>'
+labels: area/github-membership
+assignees: ''
+
+---
+
+### GitHub Username
+
+<your-GH-handle>
+
+### Motivation
+
+_Describe why you would like to be removed as maintainer._
+
+### GitHub repositories
+
+_List the repositories you would like to be removed from as a maintainer._
+
+- <repository_name>
+- <repository_name>
+
+### Checklist for _dapr/community_ maintainer
+
+- [ ] Remove maintainer from [MAINTAINERS.md](https://github.com/dapr/community/blob/master/MAINTAINERS.md).
+- [ ] Remove maintainer from [CNCF project-maintainers.csv](https://github.com/cncf/foundation/blob/main/project-maintainers.csv).
+- [ ] Remove maintainer from _Dapr Maintainers & Community Managers_ doc on Google Drive.
+- [ ] Remove maintainer from _maintainers_ role on Discord.