UNITED STATES DISTRICT COURT DISTRICT OF MASSACHUSETTS Plaintiff v. Civil Action No. Defendant NOTICE TO PARTIES IN PRO SE PRISONER LITIGATION CASES DO NOT SCAN This case has been assigned to Magistrate Judge ___________________ for all purposes. Please read the attached General Order for further information regarding this assignment. Each party is responsible for submitting this form to the Court advising that all parties consent to (or refuse) the Magistrate Judge’s jurisdiction. Each party is to file their consent or refusal on paper, with the Clerk’s Office clearly marked as DO NOT SCAN. While consent to the assignment of the case to the Magistrate Judge is entirely voluntary, and no adverse substantive consequences of any kind will redound to an attorney or party refusing consent, submission of this executed form, memorializing consent or refusal to the final assignment to the Magistrate Judge is mandatory. This document is to be filed on paper with the Clerk’s Office within thirty days after the date of service on the last party. CONSENT TO PROCEED BEFORE A U.S. MAGISTRATE JUDGE In accordance with 28 U.S.C. § 636(c) and Rule 73(b) of the Federal Rules of Civil Procedure, the undersigned pro se party or counsel of record consents to have the above named Magistrate Judge conduct all further proceedings in this case, including bench or jury trial, and order the entry of final judgment, with direct review by the First Circuit Court of Appeals if any appeal is filed. Party Represented Signature Date (If additional space is needed, additional forms may be attached) - - OR - REFUSAL TO CONSENT TO PROCEED BEFORE A U.S. MAGISTRATE JUDGE (To Be Completed If the Party Declines to Consent) In accordance with General Order 07-4 , dated December 4, 2007, and as modified by General Order 09-3 (dated March 3, 2009) and General Order 10-1 (dated February 2, 2010) the parties advise the Court that at least one party does not consent to the Magistrate Judge’s jurisdiction. The case will be randomly assigned to a U.S. District Judge for further proceedings. If you elect to have the case proceed before a U.S. District Judge, the above named Magistrate Judge shall continue to be assigned to this case to hear matters referred by the District Judge, in accordance with 28 U.S.C. § 636(b) and Rule 72 of the Federal Rules of Civil Procedure. Dated: ____________________________ BBO # Address: ___________________________________________ Signature ___________________________________________ Printed Name ___________________________________________ ___________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com