U.S. District Court for the Northern District Of Illinois Limited Attorney Appearance Form As Settlement Assistance Program Counsel Case Title: Case Number: A limited appearance is hereby filed by the undersigned as settlement assistance program counsel for (indicate the name of the party(s) being represented: By filing this appearance, undersigned counsel represents that he/she has not entered into, and will not seek to enter into, any agreement with the party for payment by the party of fees and/or costs. Attorney name (type or print): Firm: Street address: City/State/Zip: Bar ID Number: (See item 3 in instructions) Telephone Number: Email Address: ______________________________________________________________________ In order to appear before this Court an attorney must either be a member in good standing of this Court's general bar or be granted leave to appear pro hac vice as provided for by local rules 83.12 through 83.14. I declare under penalty of perjury that the foregoing is true and correct. Under 28 U.S.C.§1746, this statement under perjury has the same force and effect as a sworn statement made under oath. Executed on Attorney signature: S/ (Use electronic signature if the appearance form is filed electronically.) Revised 8/10/2015 American LegalNet, Inc. www.FormsWorkFlow.com