UNITED STATES DISTRICT COURT FOR THE DISTRICT OF RHODE ISLAND , : : Plaintiff(s) : : v. : Case No. : , : : Defendant(s) CONSENT OR DECLINATION TO JURISDICTION OF A UNITED STATES MAGISTRATE JUDGE You may consent to have your case referred to a magistrate judge, or you may withhold your consent without adverse substantive consequences. The name of any party consenting or withholding consent will not be revealed to any judge who may otherwise be involved with your case. Please indicate whether you (if you are the party) or the party you represent (if you are an attorney in the case) consents to or declines magistrate judge jurisdiction in this matter by checking one of the two boxes below. Consent to Magistrate Judge Jurisdiction In accordance with the provisions of 28 U.S.C. 247 636(c), I voluntarily consent to have a United States magistrate judge conduct all further proceedings in this case, including trial and entry of final judgment. I understand that appeal from the judgment shall be taken directly to the United States Court of Appeals for the First Circuit. OR Decline Magistrate Judge Jurisdiction In accordance with the provisions of 28 U.S.C. 247 636(c), I decline to have a United States magistrate judge conduct all further proceedings in this case, and I hereby request that this case be reassigned to a United States district judge. Name Signature (type 223/s/224 and your name) Counsel for Date COMPLETE THIS FORM AND CLICK THE E-MAIL BUTTON TO SEND IT TO THE CLERK222S OFFICE VIA YOUR EMAIL PROVIDER. YOU MAY ALSO SAVE THIS FORM AND ATTACH IT TO AN EMAIL AND SEND IT TO: RIDCONSENT@RID.USCOURTS.GOV. American LegalNet, Inc. www.FormsWorkFlow.com