ACKNOWLEDGMENT FORMNote: this form is available in fillable .pdf format on the court222s website at: http://www.nysd.uscourts.gov/judge/Gorenstein Complete this form (please print or type) or its equivalent, sign it, and send it (for receipt no later thanmidnight four business days prior to the conference) (1) to all other attorneys who will be attending the conference and (2) to Judge Gorenstein. Please read the certifications below carefully as your signature indicates your compliance with them. Name of Case:Docket Number: Civ. () (GWG)I acknowledge that my client and I must attend a settlement conference on , 20 at: .m. in Courtroom 6-B, United States Courthouse, 500 Pearl Street, New York, NY.1.I am attorney for [state name of party or parties].2.(For corporate or other non-individual clients): The name and title of the representative(s) of myclient who will attend the conference is:Name/title of insurance representative [if any]: 3.CHECK APPROPRIATE BOX AND FILL IN NAMES: a. 9 [insert name/names] will attend in person. b. 9 [insert name/names] will attendby telephone because I certify that (1) such individual(s) lives/works more than 100 milesfrom the Courthouse and (2) it would be a great hardship for such person(s) to attend asettlement conference on this or any other date. The individual(s) understands that he or shemust participate by telephone without interruption for the duration of the conference. 4.I certify that the person attending the conference (in person or by telephone) is the person withultimate responsibility for determining the settlement amount: that is, the person responsible for giving settlement authority, not someone who has received authority from another person. Inaddition, if there is an insurance carrier with authority over settlement, a representative from suchcarrier in charge of giving settlement authority will be present in person or by telephone. 5.I certify that I will promptly supply a copy of opposing counsel222s settlement letter to all persons attending the conference (by telephone or in person), and I will ensure that each person has read opposing counsel222s letter prior to the conference. 6.I certify that I have read both the Court222s Order scheduling this conference as well as the 223StandingOrder Applicable to Settlement Conferences Before Judge Gorenstein.224[signature of attorney][print attorney222s name] American LegalNet, Inc. www.FormsWorkFlow.com