Commonwealth of Massachusetts The Trial Court Probate and Family Court Department Docket No. Division Notice of Limited Appearance , Plaintiff/Petitioner v. , Defendant/Respondent On a Complaint/Petition for filed 1. The Attorney, , and the Plaintiff/Petitioner/Defendant/Respondent, have executed a written agreement whereby Attorney will provide limited representation to the Party. 2. The attorney's court appearance in this matter is limited to the following court events1 (enter date of event if known): Hearing on Order for Protection from Abuse, c.209A Temporary Orders Hearing Date Date Other motion Date Case Management Conference Date Pre-Trial Conference Date Status Conference Date Conciliation Session Date Other ADR Process Session Date 1 If the appearance does not extend to all matters to be considered at the event, identify the discrete issues within the event covered by the appearance. American LegalNet, Inc. www.FormsWorkFlow.com Trial Date Other Date 3. Upon termination of representation indicated above, the Attorney will file a Withdrawal of Limited Appearance in this Court, and serve a copy upon the party and opposing counsel/party. 4. The Attorney named above is "Attorney of Record" and available for service of documents only for those court events as described in paragraph 2 above. For all other matters, the party must be served directly, except in cases when the address has been IMPOUNDED. The party's name, address and phone number are listed below for that purpose. (If the party's address is designated as IMPOUNDED, opposing counsel or the opposing party must serve pleadings and other court documents through the Court. Inquire at the Registry of Probate for assistance in completing service to a party with an impounded address.) To the Party: If your address and/or telephone number has been IMPOUNDED, DO NOT provide it/them below. Instead, write IMPOUNDED on the address line below Signature of Party Party Address (for the purpose of service) Street Type or print Name of Party Party Telephone Number Address, continued City, State, Zip code Date ************************************************************************************************* I certify that I have this day served notice of limited appearance on all counsel and all parties not represented by counsel. Signature of Attorney Type or Print Name of Attorney Attorney Address, Street Attorney Telephone Number Address, continued City, State, Zip code BBO No. Date American LegalNet, Inc. www.FormsWorkFlow.com