UNITED STATES DISTRICT COURT DISTRICT OF MASSACHUSETTS _______________________________ Plaintiff v. Civil Action Number __________________ _______________________________ Defendant LIMITED APPOINTMENT OF COUNSEL PURSUANT TO THE PRO SE MEDIATION PROGRAM The Court hereby appoints the herein named attorney to represent the pro se party solely for the limited purpose of assisting the pro se party in connection with mediation proceedings in this case. Appointed counsel shall not be obligated to conduct any discovery, to prepare or respond to any motions and shall not be responsible for the trial of this case. On notice to the Court, appointed counsel may seek to end the representation of the pro se party upon completion of the mediation proceedings. Name of Appointed Counsel: ________________________________________________ Law Firm: ________________________________________________ Street Address: ________________________________________________ Suite Number: ________________________________________________ City, State & Zip Code: ________________________________________________ Telephone Number: ________________________________________________ I hereby acknowledge that I have read, understand and agree to the terms of this Limited Appointment of Counsel Pursuant to the Pro Se Mediation Program. ________________________ Date ________________________________________________ Pro se party ________________________ Date ________________________________________________ Counsel