UNITED STATES DISTRICT COURT DISTRICT OF CONNECTICUT , Plaintiff V. Case No. [Put case number here] , Defendant CONSENT TO ELECTRONIC NOTICE BY SELF-REPRESENTED LITIGANT A. [Complete the first line for electronic notification from the court] I, hereby consent to the court (name of self-represented litigant) using my email address, as listed below, for the purpose of sending me notification of orders and notices issued by the court. B. [Complete the second line for electronic service from opposing counsel; DO NOT COMPLETE THIS LINE IF YOU WANT OPPOSING COUNSEL TO SEND PAPERS BY REGULAR MAIL] I, hereby consent to opposing (name of self-represented litigant) counsel using my email address, as listed below, for the purpose of sending me papers filed with the court. In the event I change my email provider or discontinue my email service, I will notify the court immediately of the address change so my court records may be updated. Name of Self-represented Litigant Street Address City, State, Zip Code Telephone Email Address Date Signature American LegalNet, Inc. www.FormsWorkFlow.com Certificate of Service I hereby certify that on [date], a copy of the foregoing Motion by Self- represented Litigant to Participate in Electronic Filingas filed and served by mail on the following: [insert name and address of every person served]. Signature of Self-represented Litigant Revised: November 29, 2017 American LegalNet, Inc. www.FormsWorkFlow.com