UNITED STATES DISTRICT COURT DISTRICT OF ALASKA OFFICE OF THE CLERK LESLEY K. ALLEN Clerk of Court 222 W. 7TH Avenue, Box 4 Anchorage, AK 99513 Date: Insert Date To: CASE CAPTION From: Brenda Kappler, Deputy Clerk Re: DECLINATION OF CONSENT FORM This case has been assigned to United States Magistrate Judge INSERT NAME for all purposes, including trial, final entry of judgment, and direct review by the Ninth Circuit Court of Appeals. See 28 USC 636(c), Federal Rule of Civil Procedure 73, and Miscellaneous General Order 19-03. Consent to the assignment of a USDC AK Magistrate Judge is voluntary. If a party declines consent, the identity of the party declining consent will not be communicated to any judge, and the Clerk will immediately reassign the case to a District Judge by random selection. Any party may decline consent by signing at the bottom and emailing this form to DecConsent@akd.uscourts.gov or mailing to the above address. The form must be received by the court no later than Insert Date. Do not electronically file this form. Each party will be deemed to have knowingly and voluntarily consented to proceed before the assigned Magistrate Judge, if this form is not returned by the above date. DECLINATION OF CONSENT I hereby decline to consent to the assignment of this case to a Magistrate Judge. I request the case be reassigned to a U.S. District Judge. Signature Plaintiff/Defendant Date Signed (Party Represented) American LegalNet, Inc. www.FormsWorkFlow.com