IN THE UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF PENNSYLVANIA : CIVIL ACTION NO. : v. : CONSENT TO or DECLINATION OF : JURISDICTION OF A COMMISSIONER OF SOCIAL : MAGISTRATE JUDGE SECURITY : : In accordance with the provisions of 28 U.S.C. 247 636(c), Fed. R. Civ. P. 72, and Local Rule 72.1, the party(ies) to the above-captioned matter hereby: Voluntarily consent(s) to have a United States Magistrate Judge conduct all further proceedingsin this case to disposition, with direct review by the Third Circuit Court of Appeals in the eventan appeal is filed. OR Acknowledges the availability of a United States Magistrate Judge but declines to consent andrequests the case be reassigned to a United States District Judge. If a party declines to consent,this matter shall be referred to the assigned Magistrate Judge for review and preparation of aReport and Recommendation to the assigned District Judge. Failure to complete and submit this Consent/Declination Form within twenty-one (21) days may be deemed consent to the jurisdiction of a Magistrate Judge, and the Magistrate Judge will exercise jurisdiction for all purposes under 28 U.S.C. 247 636(c). See Roell v. Withrow, 538 U.S. 580 (2003). Party Represented Attorney/Pro Se Litigant Signature Date Signed American LegalNet, Inc. www.FormsWorkFlow.com