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UNITED STATES DISTRICT COURT DISTRICT OF MASSACHUSETTS ______________________________________ Plaintiff v. ______________________________________ Defendant NOTICE This case has been assigned to Magistrate Judge ___________________ for all purposes. Please read the attached General Order for further information regarding this assignment. Plaintiff, or defendant if the case is initiated by a Notice of Removal, is responsible for submitting this form to the Court advising that all parties consent to the Magistrate Judge's jurisdiction, or indicating that the consent is not unanimous. One document is to be filed. While consent to the assignment of the case to the Magistrate Judge is entirely voluntary, and no adverse substantive consequences of any kind will redound to an attorney or party refusing consent, submission of this executed form, memorializing consent or refusal to the final assignment to the Magistrate Judge is mandatory. This document is to be electronically filed with the Court within thirty days after the date of service on the last party. CONSENT TO PROCEED BEFORE A U.S. MAGISTRATE JUDGE (To Be Completed Only If All Parties Consent) In accordance with 28 U.S.C. § 636(c) and Rule 73(b) of the Federal Rules of Civil Procedure, the undersigned pro se party or counsel of record consent to have the above named Magistrate Judge conduct all further proceedings in this case, including bench or jury trial, and order the entry of final judgment, with direct review by the First Circuit Court of Appeals if any appeal is filed. Party Represented Signature Date Civil Action No. __________________________

(If additional space is needed, additional forms may be attached) - - OR - REFUSAL TO CONSENT TO PROCEED BEFORE A U.S. MAGISTRATE JUDGE (To Be Completed If Any Party Declines to Consent - Please DO NOT Identify the Party) In accordance with General Order 07-4 , dated December 4, 2007, the parties advise the Court that at least one party does not consent to the Magistrate Judge's jurisdiction. The case will be randomly assigned to a U.S. District Judge for further proceedings. If you elect to have the case proceed before a U.S. District Judge, the above named Magistrate Judge shall continue to be assigned to this case to hear matters referred by the District Judge, in accordance with 28 U.S.C. § 636(b) and Rule 72 of the Federal Rules of Civil Procedure. Dated: ____________________________ ___________________________________________ Plaintiff or Removing Party (through counsel, if appropriate) ___________________________________________ ___________________________________________ ___________________________________________

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