Case 1:05-cv-00751-JJF Document 1-3 Filed 10/27/2005 Page 1 of 1
A0 FORM 85 RECEIPT (REV. 9/O4! I
United States District Court for the District of Delaware
Civil Action No.
ACKNOWLED GMENT
OF RECEIPT FOR AO FORM 85
NOTICE OFA VAILABILITY OFA
UNITED STATESMAGISTRATE JUDGE
T O EXERCISE J URISDI C T I ON
I HEREBY ACKNOWLEDGE RECEIPT OF EL COPIES OF AO FORM 85.
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_ (Date forms issued) (Signature of Party or their Re resentative)
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‘ L 1 (Printed name of Party or their resentative) `
Note: Comgleted receigt will be tiled in the Civil Action