COURT DIVISION DOCKET NUMBERNOTICE OF LIMITED APPEARANCEwww.mass.gov/courts Trial Court of Massachusetts District Court Department YEAR*COURT NUMBERCASE TYPE**CASE NUMBER*e.g. "10" , "11"**e.g. "CV" , "SC" PARTY FOR WHOM LIMITED REPRESENTATION TO BE PROVIDEDTo the Clerk-Magistrate:Please enter my limited appearance for the above named and undersigned party in the above numbered court action. I acknowledge that I have executed a written agreement with this party to provide limited representation in this matter, as is described below. I also certify that I have served this Notice of Limited Appearance on all counsel and all parties not represented by counsel, and that I have completed an information session on Limited Assistance Representation required by Standing Order No. 1-11 of the District Court Department. DESCRIPTION OF EVENT AND/OR PURPOSE FOR WHICH ATTORNEY AND CLIENT HAVE AGREED LIMITED REPRESENTATION TO BE PROVIDED(Include event date if known) ATTORNEY NAMEATTORNEY FIRMSTREET ADDRESSCITY/TOWNSTATEZIP CODE B.B.O. NUMBER (Required)TELEPHONE NUMBEREMAIL ADDRESS XXSIGNATURE OF ATTORNEYDATESIGNATURE OF PARTYDATE CASE NAMEV. NOTICE OF WITHDRAWAL OF LIMITED APPEARANCEREVISED NOTICE OF LIMITED APPEARANCE To the Clerk-Magistrate:To the Clerk-Magistrate:Please enter my Withdrawal of Limited Appearance for the above named and undersigned party in the above numbered court action. I certify that I have served this Notice of Withdrawal of Limited Appearance on all counsel and all parties not represented by counsel. SIGNATURE OF ATTORNEYDATEDATESIGNATURE OF PARTYXXPlease enter a Revised Notice of Limited Appearance for the above named and undersigned party in the above numbered court action, filed with the informed consent of the party, changing or expanding the original terms of the limited representation in the manner described below. I certify that I have served this Revised Notice of Limited Appearance on all counsel and all parties not represented by counsel. DESCRIPTION OF EVENT AND/OR PURPOSE FOR WHICH ATTORNEY AND CLIENT HAVE AGREED LIMITED REPRESENTATION TO BE PROVIDED SIGNATURE OF ATTORNEYSIGNATURE OF PARTYDATEDATE XX (Include event date if known)INSTRUCTIONS TO ATTORNEY Remember to retain a copy of the Notice of Limited Appearance you file with the court. This copy should be used in the event you file a Revised Notice of Limited Appearance, as well as when you later file your Notice of Withdrawal of Limited Appearance. When using the copy for either purpose, both you and your client must sign and date the copy you file with the court.(Plaintiff/Petitioner v. Defendant/Respondent) American LegalNet, Inc. www.FormsWorkFlow.com