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IN THE UNITED STATES DISTRICT COURT FOR THE CENTRAL DISTRICT OF ILLINOIS Danville/Urbana Division ) ) ) ) ) ) ) )

Plaintiff, v.

Case No.

Defendant.

CONSENT TO PROCEED BEFORE A UNITED STATES MAGISTRATE JUDGE FOR LIMITED AND SPECIFIC PROCEEDINGS In accordance with the provisions of 28 U.S.C. § 636(c) and Fed.R.Civ.P. 73, the parties in this case hereby voluntarily waive their rights to proceed before a United States District Judge and consent to a United States Magistrate Judge for the limited and specific purpose of ________________________ __________________________________________________________________________________. FOR THE PLAINTIFF(S): __________________________________ DATE: ___________________________ __________________________________ DATE: ___________________________ __________________________________ DATE: ___________________________
(All plaintiffs or attorneys for plaintiffs must sign)

FOR THE DEFENDANT(S): ______________________________________ DATE: ______________________________ _____________________________________ DATE: ______________________________ _____________________________________ DATE: ______________________________
(All defendants or attorneys for defendants must sign)

ORDER IT IS ORDERED that this case is referred to the Honorable David G. Bernthal, United States Magistrate Judge, for the limited and specific purpose of _______________________________________ ________________________________________________________________________ in accordance with 28 U.S.C. § 636(c) and Fed.R.Civ.P. 73, and the foregoing consent of the parties. ENTER this _______ day of ______________, 19___.

_________________________________________ UNITED STATES DISTRICT JUDGE
(NOTE: Return this form to the Clerk of Court only if all parties have consented on this form to proceed before a Magistrate Judge.)