UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF OKLAHOMA Plaintiff, v. CAROLYN W. COLVIN, Acting Commissioner, Social Security Administration, Defendant. ) ) ) ) ) ) ) ) ) ) Case No. STATEMENT AS TO MAGISTRATE JUDGE JURISDICTION THIS FORM SHALL BE USED ONLY FOR SOCIAL SECURITY CASES IN WHICH A MAGISTRATE JUDGE IS INITIALLY ASSIGNED PURSUANT TO GENERAL ORDER 16-08 INSTRUCTIONS: 1. Enter the filing party's name. 2. Check one of the two boxes to indicate whether the party chooses to consent or decline magistrate judge jurisdiction in this case. 3. Complete and sign the bottom of the form. 4. File the executed form with the Court using the appropriate Statement event located under: Civil > Case Specific Documents > Social Security Documents. Party Name: CONSENT to Magistrate Judge Jurisdiction In accordance with the provisions of 28 U.S.C. § 636(c), I voluntarily consent to have the assigned United States Magistrate Judge conduct all further proceedings in this case, including entry of final judgment. I understand that any appeal from the judgment shall be taken directly to the United States Court of Appeals for the Tenth Circuit. OR DECLINE Magistrate Judge Jurisdiction In accordance with the provisions of 28 U.S.C. § 636(c), I decline to have the assigned United States Magistrate Judge conduct all further proceedings in this case, and I hereby request that this case be reassigned to a United State District Judge for any dispositive matter. Date: Signature: Print Name: OK State Bar Number (if applicable): E-Mail Address: Firm Name: Mailing Address: City Phone Number: Fax Number: American LegalNet, Inc. www.FormsWorkFlow.com State ZIP Code Statement as to Magistrate Judge Jurisdiction CV-30 (7/2016)