UNITED STATES DISTRICT COURT DISTRICT OF SOUTH CAROLINA
FORMS FOR FILING CASES PRO SE (Representing Yourself) Non-Prisoner
Revised October 3, 2007
FORM A: Pro Se [Non-Prisoner] Complaint Form FORM B: Summons FORM C: Civil Cover Sheet (Form JS-44) FORM D: Pro Se Party's Answers to Rule 26.01 Interrogatories FORM E: Application to Proceed Without Prepayment of Fees and Affidavit (IFP Application) FORM F: Notice of Lawsuit and Request for Waiver of Service for Summons FORM G: Waiver of Service of Summons FORM H: Notice of Availability of a United States Magistrate Judge to Exercise Jurisdiction
IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF SOUTH CAROLINA Pro Se [Non-Prisoner] Complaint Form
[Enter the full name of the plaintiff in this action] ________________________________________ ______________________________________ v. [Enter the full name of each defendant in this action. If possible, please list only one defendant per line.] ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ _______________________________ ) Civil Action No. )______________________ ) (to be assigned by Clerk) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) )
If allowed by statute, do you wish to have a trial by jury? Yes _____
[If any answer requires additional space, please use additional paper and attach hereto.] I. PREVIOUS LAWSUITS A. Have you begun other lawsuits in state or federal court dealing with the same facts involved in this action? Yes _______ No ______
If your answer to A is Yes, describe the lawsuit in the space below. [If more than one lawsuit, describe on another sheet of paper using the same outline.] 1. Parties to this previous lawsuit: Plaintiff: Defendant(s): 2. 3. 4. 5. 6. 7. Court:
(If federal court, name the district; if state court, name the county)
Docket Number: Name(s) of Judge(s) to whom case was assigned: Status of Case:
(For example, was the case dismissed? Settled? Appealed? Still Pending?)
Date lawsuit was filed: Date of disposition (if concluded):
C. Do you have any other lawsuit(s) pending in the federal court in South Carolina? Yes _______ II. PARTIES In Item A below, place your name and address in the space provided. [If additional plaintiffs, do the same on another sheet of paper.] A. Name of Plaintiff: Address: In Item B below, place the full name of the defendant, and his/her/its address, in the space provided. Use Item C for additional defendants, if any. B. Name of Defendant: Address: No _______
C. Additional Defendants (provide the same information for each defendant as listed in Item B above): _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________ III. STATEMENT OF CLAIM State here, as briefly as possible, the facts of your case. Describe how each defendant is involved. Include also the name(s) of other persons involved, dates, and places. Do not give any legal arguments or cite any cases or statutes. If you intend to allege a number of related claims, number and set forth each claim in a separate paragraph. Use as much space as you need. Attach extra sheets of paper if necessary. _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
III. STATEMENT OF CLAIM - continued. _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _________________________________________________________________
IV. RELIEF. State briefly and exactly what you want this court to do for you. _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ ____________________________________________________________________________
I declare under penalty of perjury that the foregoing is true and correct.
Signed this ________ day of _______________________________, 20____.
______________________________________________ Signature of Plaintiff
AO440 (Rev. 8/01) Summons in a Civil Action
UNITED STATES DISTRICT COURT
DISTRICT OF SOUTH CAROLINA
, Plaintiff, v. , Defendant. TO: (Name and address of defendant) Name: Address: City, State Zip:
SUMMONS IN A CIVIL CASE
YOU ARE HEREBY SUMMONED and required to file with the Clerk of this Court and serve upon
PLAINTIFF'S ATTORNEY, or if unrepresented, plaintiff(s):
Name: Address: City, State Zip:
an answer to the complaint which is served upon you, within ___________ days after service of this summons upon you, exclusive of the day of service. If you fail to do so, judgment by default will be taken against you for the relief demanded in the complaint. You must also file your answer with the Clerk of this Court within a reasonable period of time after service.
___________________________________ Clerk ___________________________________ By Deputy Clerk
AO 440 (Rev 1/90) Summons in a Civil Action
RETURN OF SERVICE
DATE Service of the Summons and Complaint was made by me1 NAME OF SERVER (PRINT) TITLE
Check one box below to indicate appropriate method of service G G Served personally upon the defendant. Place where served: __________________________________________ __________________________________________________________________________________________ Left copies thereof at the defendant's dwelling house or usual place of abode with a person of suitable age and discretion then residing therein. Name of person with whom the summons and complaint were left: _____________________________________ Returned unexecuted: ________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Other (specify): _____________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________
STATEMENT OF SERVICE FEES
TRAVEL SERVICES TOTAL
DECLARATION OF SERVER
I declare under penalty of perjury under the laws of the United States of America that the foregoing information contained in the Return of Service and Statement of Service Fees is true and correct.
Executed on _________________________ Date
_____________________________________________________ Signature of Server
_____________________________________________________ Address of Server
1) As to who may serve a summons, see Rule 4 of the Federal Rules of Civil Procedure.
JS44 (Rev. 11/04)
CIVIL COVER SHEET
The JS44 civil cover sheet and the information contained herein neither replace nor supplement the filing and service of pleadings or other papers as required by law, except as provided by local rules of court. This form, approved by the Judicial Conference of the United States in September 1974, is required for the use of the Clerk of Court for the purpose of initiating the civil docket sheet. (SEE INSTRUCTIONS ON THE REVERSE OF THE FORM.)
I (a) PLAINTIFFS
(b) COUNTY OF RESIDENCE OF FIRST LISTED PLAINTIFF __________
(EXCEPT IN U.S. PLAINTIFF CASES)
COUNTY OF RESIDENCE OF FIRST LISTED DEFENDANT ____________ (IN U.S. PLAINTIFF CASES ONLY) NOTE: IN LAND CONDEMNATION CASES, USE THE LOCATION OF THE TRACT OF LAND INVOLVED ATTORNEYS (IF KNOWN)
ATTORNEYS (FIRM NAME, ADDRESS, AND TELEPHONE NUMBER)
II. BASIS OF JURISDICTION
G 1 U.S. Government Plaintiff G 2 U.S. Government Defendant G3 G4
(PLACE AN X IN ONE BOX ONLY
III. CITIZENSHIP OF PRINCIPAL PARTIES
(For Diversity Cases Only) Citizen of This State PTF DEF G1 G1
(PLACE AN X IN ONE BOX
FOR PLAINTIFF AND ONE BOX FOR DEFENDANT)
Federal Question (U.S. Government Not a Party) Diversity (Indicate Citizenship of Parties IN Item III)
Citizen of Another State G 2 G 2 Citizen or Subject of a Foreign Country G3 G3
PTF Incorporated or Principal Place G 4 of Business in This State Incorporated and Principal Place G 5 Of Business in Another State Foreign Nation G6
DEF G4 G5 G6
V. NATURE OF SUIT (PLACE AN "x" IN ONE BOX ONLY)
G 110 G 120 G 130 G 140 G 150 G 151 G 152 G 153 G 160 G 190 G 195 Insurance Marine Miller Act Negotiable Instrument Recovery of Overpayment & Enforcement of Judgment Medicare Act Recovery of Defaulted Student Loans (Excl. Veterans) Recovery of Overpayment of Veteran's Benefits Stockholders' Suits Other Contract Contract Product Liability
PERSONAL INJURY G 310 Airplane G 315 Airplane Product Liability G 320 Assault, Libel & Slander G 330 Federal Employers' Liability G 340 Marine G 345 Marine Product Liability G 350 Motor Vehicle G 355 Motor Vehicle Product Liability G 360 Other Personal Injury PERSONAL INJURY G 362 Personal Injury -- Med Malpractice G 365 Personal Injury -- Product Liability G 368 Asbestos Personal Injury Product Liability PERSONAL PROPERTY G 370 Other Fraud G 371 Truth in Lending G 380 Other Personal Property Damage G 385 Property Damage Product Liability
G 610 Agriculture G 620 Other Food & Drug G 625 Drug Related Seizure of Property 21 USC 881 G 630 Liquor Laws G 640 R.R. & Truck G 650 Airline Regs G 660 Occupational Safety/Health G 690 Other
G 422 Appeal 28 USC 158 G 423 Withdrawal 28 USC 157 G400 G 410 G 430 G 450 G 460 G 470 G 810 G 850 G 875 G 891 G 892 G 893 G 894 G 895 G 900 G 950 G 890
State Reapportionment Antitrust Banks and Banking Commerce/ICC Rates/etc. Deportation Racketeer Influenced and Corrupt Organizations Selective Service Securities/Commodities/ Exchange Customer Challenge 12 USC 3410 Agricultural Acts Economic Stabilization Act Environmental Matters Energy Allocation Act Freedom of Information Act Appeal of Fee Determination Under Equal Access to Justice Constitutionality of State Statutes Other Statutory Actions
G 820 Copyrights G 830 Patent G 840 Trademark G 861 G 862 G 863 G 864 G 865
G 710 Fair Labor Standards Act G 720 Labor/Mgmt. Relations G 730 Labor/Mgmt. Reporting & Disclosure Act G 740 Railway Labor Act G 790 Other Labor Litigation G 791 Empl. Ref. Inc. Security Act
HIA (1395ff) Black Lung (923) DIWC/DIWW (405(g)) SSID Title XVI RSI (405(g))
G 210 G 220 G 230 G 240 G 245 G 290 Land Condemnation Foreclosure Rent Lease & Ejectment Torts to Land Tort Product Liability All Other Real Property
G 441 Voting G 442 Employment G 443 Housing/ Accommodations G 444 Welfare G 440 Other Civil Rights
G 510 Motions to Vacate Sentence Habeas Corpus: G 530 General G 535 Death Penalty G 540 Mandamus & Other G 550 Other
FEDERAL TAX SUITS
G 870 Taxes (U.S. Plaintiff or Defendant) G 871 IRS -- Third Party 26 USC 7609
VI. ORIGIN(PLACE AN x IN ONE BOX ONLY)
G 1Original Proceeding G 2 Removed from State Court G 3 Remanded from Appellate Court G 4 Reinstated or Reopened Transferred from G 5 another district (Specify) G 6 Multidistrict Litigation
Appeal to District Judge from G 7 Magistrate Judgment
VII. REQUESTED IN CHECK IF THIS IS A CLASS ACTION DEMAND $ Check YES only if demanded IN complaint: COMPLAINT: G UNDER F.R.C.P. 23 JURY DEMAND: G YESG NO VIII. RELATED CASE(S) (See Instructions) IF ANY JUDGE _________________________ DOCKET NUMBER ____________________
DATE FOR OFFICE USE ONLY RECEIPT # ___________ AMOUNT ______________ APPLYING IFP _____________ JUDGE _________________ MAG. JUDGE ___________ SIGNATURE OF ATTORNEY OF RECORD
INSTRUCTIONS FOR ATTORNEYS COMPLETING CIVIL COVER SHEET FORM JS-44
Authority for Civil Cover Sheet
The JS-44 civil cover sheet and the information contained herein neither replaces nor supplements the filings and service of pleading or other papers as required by law, except as provided by local rules of court. This form, approved by the Judicial Conference of the United States in September 1974, is required for the use of the Clerk of Court for the purpose of initiating the civil docket sheet. Consequently a civil cover sheet is submitted to the Clerk of Court for each civil complaint filed. The attorney filing a case should complete the form as follows: I.(a) Plaintiffs - Defendants. Enter names (last, first, middle initial) of plaintiff and defendant. If the plaintiff or defendant is a government agency, use only the full name or standard abbreviations. If the plaintiff or defendant is an official within a government agency, identify first the agency and then the official, giving both name and title. (b) County of Residence. For each civil case filed, except U.S. plaintiff cases, enter the name of the county where the first listed plaintiff resides at the time of filing. In U.S. plaintiff cases, enter the name of the county in which the first listed defendant resides at the time of filing. (NOTE: In land condemnation cases, the county of residence of the "defendant" is the location of the tract of land involved). (c) Attorneys. Enter firm name, address, telephone number, and attorney of record. If there are several attorneys, list them on an attachment, noting in this section "(see attachment)". II. Jurisdiction. The basis of jurisdiction is set forth under Rule 8 (a), F.R.C.P., which requires that jurisdictions be shown in pleading. Place an "X" in one of the boxes. If there is more than one basis of jurisdiction, precedence is given in the order shown below. United States plaintiff. (1) Jurisdiction is based on 28 U.S.C. 1345 and 1348. Suits by agencies and officers of the United States are included here. United States defendant. (2) When the plaintiff is suing the United States, its officers or agencies, place an X in this box. Federal question. (3) This refers to suits under 28 U.S.C. 1331, where jurisdiction arises under the Constitution of the United States, an amendment to the Constitution, an act of Congress or a treaty of the United States. In cases where the U.S. is a party, the U.S. plaintiff or defendant code takes precedence, and box 1 or 2 should be marked. Diversity of citizenship. (4)This refers to suits under 28 U.S.C. 1332, where parties are citizens of different states. When Box 4 is checked, the citizenship of the different parties must be checked. (See Section III below; federal question actions take precedence over diversity cases.) III. Residence (citizenship) of Principal Parties. This section of the JS-44 is to be completed if diversity of citizenship was indicated above. Mark this section for each principal party. IV. Cause of Action. Report the civil statute directly related to the cause of action and give a brief description of the cause. V. Nature of Suit. Place an "X" in the appropriate box. If the nature of suit cannot be determined, be sure the cause of action, in Section IV above, is sufficient to enable the deputy clerk or the statistical clerks in the Administrative Office to determine the nature of suit. If the cause fits more than one nature of suit, select the most definitive. VI. Origin. Place an "X" in one of the seven boxes. Original Proceedings. (1) Cases which originate in the United States district courts. Removed from State Court. (2) Proceedings initiated in state courts may be removed to the district courts under Title 28 U.S.C., Section 1441. When the petition for removal is granted, check this box. Remanded from Appellate Court. (3) Check this box for cases remanded to the district court for further action. Use the date of remand as the filing date. Reinstated or Reopened. (4) Check this box for cases reinstated or reopened in the district court. Use the reopening date as the filing date. Transferred from Another District. (5)For cases transferred under Title 28 U.S.C. Section 1404(a). Do not use this for within district transfers or multidistrict litigation transfers. Multidistrict Litigation. (6) Check this box when a multidistrict case is transferred into the district under authority of Title 28 U.S.C. Section 1407. When this box is checked, do not check (5) above. Appeal to District Judge from Magistrate Judgment. (7) check this box for an appeal from a magistrate's decision. VII. Requested in Complaint. Class Action. Place an "X" in this box if you are filing a class action under Rule 23, F.R.Cv.P. Demand. In this space enter the dollar amount (in thousands of dollars) being demanded or indicate other demand such as a preliminary injunction. Jury Demand. Check the appropriate box to indicate whether or not a jury is being demanded. VIII. Related Cases. This section of the JS-44 is used to reference relating pending cases if any. If there are related pending cases, insert the docket numbers and the corresponding judge names for such cases. Date and Attorney Signature. Date and sign the civil cover sheet. (rev. 07/89)
UNITED STATES DISTRICT COURT DISTRICT OF SOUTH CAROLINA
) C/A No. ____________________________ ) ) ) ) ) Pro Se Party's Answers to ) Rule 26.01 Interrogatories ) ) ) ) ) ) ) )
(A) State the full name, address and telephone number of all persons or legal entities who may have a subrogation interest in each claim and state the basis and extent of said interest.
(B) As to each claim, state whether it should be tried jury or non jury and why.
(C) State the basis for asserting the claim in the division in which it was filed (or the basis of any challenge to the appropriateness of the division).
(D) Is this action related in whole or in part to any other matter filed in this District, whether civil or criminal? If so, provide: (1) a short caption and the full case number of the related action; (2) an explanation of how the matters are related; and (3) a statement of the status of the related action. Please disclose any cases which may be related regardless of whether they are still pending. Note: Whether cases are related such that they should be assigned to a single judge will be determined by the Clerk of Court based on a determination of whether the cases: arise from the same or identical transactions, happenings or events; involve the identical parties or property; or for any other reason would entail substantial duplication of labor if heard by different judges.
(E) [Pro Se Defendants only.] If the defendant is improperly identified, give the proper identification and state whether the party(ies) submitting these responses will accept service of an amended summons and pleading reflecting the correct identification.
(F) [Pro Se Defendants only.] If you contend that some other person or legal entity is, in whole or in part, liable to you or the party asserting a claim against you in this matter, identify such person or entity and describe the basis of said liability.
I declare under penalty of perjury that the foregoing is true and correct.
Signed this ______________ day of _________________________________, 20___.
Signature of Party Responding
OAO 240 (Rev. 10/03)
UNITED STATES DISTRICT COURT
APPLICATION TO PROCEED WITHOUT PREPAYMENT OF FEES AND AFFIDAVIT
declare that I am the (check appropriate box) G other
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under 28 USC §1915 I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief sought in the complaint/petition/motion. In support of this application, I answer the following questions under penalty of perjury: 1. Are you currently incarcerated? G Yes G No (If "No," go to Part 2)
If "Yes," state the place of your incarceration Are you employed at the institution? Do you receive any payment from the institution?
Attach a ledger sheet from the institution(s) of your incarceration showing at least the past six months' transactions. 2. Are you currently employed? a. G Yes G No
If the answer is "Yes," state the amount of your take-home salary or wages and pay period and give the name and address of your employer.
If the answer is "No," state the date of your last employment, the amount of your take-home salary or wages and pay period and the name and address of your last employer.
In the past 12 twelve months have you received any money from any of the following sources? a. b. c. d. e. f. Business, profession or other self-employment Rent payments, interest or dividends Pensions, annuities or life insurance payments Disability or workers compensation payments Gifts or inheritances Any other sources G G G G G G Yes Yes Yes Yes Yes Yes G G G G G G No No No No No No
If the answer to any of the above is "Yes," describe, on the following page, each source of money and state the amount received and what you expect you will continue to receive.
AO 240 Reverse (Rev. 10/03)
AO 240 Reverse (Rev. 10/03)
Do you have any cash or checking or savings accounts? If "Yes," state the total amount.
Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or any other thing of value? G Yes G No If "Yes," describe the property and state its value.
List the persons who are dependent on you for support, state your relationship to each person and indicate how much you contribute to their support.
I declare under penalty of perjury that the above information is true and correct.
Signature of Applicant
NOTICE TO PRISONER: A Prisoner seeking to proceed without prepayment of fees shall submit an affidavit stating all assets. In addition, a prisoner must attach a statement certified by the appropriate institutional officer showing all receipts, expenditures, and balances during the last six months in your institutional accounts. If you have multiple accounts, perhaps because you have been in multiple institutions, attach one certified statement of each account.
AO 398 (12/93)
UNITED STATES DISTRICT COURT DISTRICT OF SOUTH CAROLINA
_________________ DIVISION ________________________________________ ) Plaintiff(s) ) ) v. ) ) ________________________________________ ) Defendant(s) ) TO: AS C/A No.:_________________________
NOTICE OF LAWSUIT AND REQUEST FOR WAIVER OF SERVICE FOR SUMMONS
(A)______________________________________________________________________________ (B) of (C)_____________________________________________
A lawsuit has been commenced against you (or the entity on whose behalf you are addressed). A copy of the complaint is attached to this notice. It has been filed in the United States District court for the District of South Carolina and has been assigned docket number (D)________________________. This is not a formal summons or notification from the court, but rather my request that you sign and return the enclosed waiver of service in order to save the cost of serving you with a judicial summons and an additional copy of the complaint. The cost of service will be avoided if I receive a signed copy of the waiver within (E)________ days after the date designated below as the date on which this Notice and Request is sent. I enclosed a stamped and addressed envelope (or other means of cost-free return) for your use. An extra copy of the waiver is also attached for your records. If you comply with this request and return the signed waiver, it will be filed with the court and no summons will be served on you. The action will then proceed as if you had been served on the date the waiver is filed, except that you will not be obligated to answer the complaint before 60 days from the date designated below as the date on which this notice is sent (or before 90 days from that date if your address is not in any judicial district of the United States). If you do not return the signed waiver within the time indicated, I will take appropriate steps to effect formal service in a manner authorized by the Federal Rules of Civil Procedure and will then, to the extent authorized by those Rules, ask the court to require you (or the party on whose behalf you are addressed) to pay the full costs of such service. In that connection, please read the statement concerning the duty of parties to waive the service of the summons which is set forth at the foot of the waiver form. I affirm that this request is being sent to you on behalf of the plaintiff this __________ day of ______________________, 20____. ___________________________________________________ Signature of Plaintiff's Attorney or Unrepresented Plaintiff
A - Name of individual defendant (or name of officer or agent of corporate defendant) B - Title or other relationship of individual to corporate defendant C - Name of corporate defendant, if any D - District E - Docket number of action F - Addressees must be given at least 30 days in which to return waiver (60 days if located in foreign country)
AO 399 (12/93)
UNITED STATES DISTRICT COURT
DISTRICT OF SOUTH CAROLINA
) ) ) ) ) ) )
C/A No.:__________________________________ WAIVER OF SERVICE OF SUMMONS
I acknowledge receipt of your request that I waive service of a summons in this action. I have also received a copy of the complaint in the action, two copies of this instrument, and a means by which I can return the signed waiver to you without cost to me. I agree to save the cost of service of a summons and an additional copy of the complaint in this lawsuit by not requiring that I (or the entity on whose behalf I am acting) be served with judicial process in the manner provided for by Rule 4 of the Federal Rules of Civil Procedure. I (or the entity on whose behalf I am acting) will retain all defenses or objections to the lawsuit or to the jurisdiction or venue of the court except for objections based on a defect in the summons or in the service of the summons. I understand that a judgment may be entered against me (or the party on whose behalf I am acting) if an answer or motion under Rule 12 is not served upon you within 60 days after ______________________________ (date request was sent), or within 90 days after that date if the request was sent outside the United States. __________________________
As _______________________________________________ Of _______________________________________________
Duty to Avoid Unnecessary Costs of Service of Summons Rule 4 of the Federal Rules of Civil Procedure requires certain parties to cooperate in saving unnecessary costs of service of the summons and complaint. A defendant located in the United States who, after being notified of an action and asked by a plaintiff located in the United States to waive service of a summons, fails to do so will be required to bear the cost of such service unless good cause be shown for its failure to sign and return the waiver. It is not good cause for a failure to waive service if that party believes that the complaint is unfounded or that the action has been brought in an improper place or in a court that lacks jurisdiction over the subject matter of the action or over its person or property. A party who waives service of the summons retains all defenses and objections (except any relating to the summons or to the service of the summons), and may later object to the jurisdiction of the court or to the place where the action has been brought. A defendant who waives service must within the time specified on the waiver form serve on the plaintiff's attorney (or unrepresented plaintiff) a response to the complaint and must also file a signed copy of the response with the court. If the answer or motion is not served within this time, a default judgment may be taken against that defendant. By waiving service, a defendant is allowed more time to answer than if the summons had actually been served when the request for waiver of service was received.
AO 85 (Rev. 8/98) Notice, Consent, and Order of Reference -- Exercise of Jurisdiction by a United States Magistrate Judge
UNITED STATES DISTRICT COURT
District of South Carolina , Plaintiff v. Case Number: , Defendant NOTICE, CONSENT, AND ORDER OF REFERENCE -- EXERCISE OF JURISDICTION BY A UNITED STATES MAGISTRATE JUDGE
NOTICE OF AVAILABILITY OF A UNITED STATES MAGISTRATE JUDGE TO EXERCISE JURISDICTION
In accordance with the provisions of 28 U.S.C. 636(c), and Fed.R.Civ.P. 73, you are hereby notified that a United States magistrate judge of this district court is available to conduct any or all proceedings in this case including a jury or nonjury trial, and to order the entry of a final judgment. Exercise of this jurisdiction by a magistrate judge is, however, permitted only if all parties voluntarily consent. You may, without adverse substantive consequences, withhold your consent, but this will prevent the court's jurisdiction from being exercised by a magistrate judge. If any party withholds consent, the identity of the parties consenting or withholding consent will not be communicated to any magistrate judge or to the district judge to whom the case has been assigned. An appeal from a judgment entered by a magistrate judge shall be taken directly to the United States court of appeals for this judicial circuit in the same manner as an appeal from any other judgment of a district court.
CONSENT TO THE EXERCISE OF JURISDICTION BY A UNITED STATES MAGISTRATE JUDGE
In accordance with the provisions of 28 U.S.C. § 636(c) and Fed.R.Civ.P. 73, the parties in this case consent to have a United States magistrate judge conduct any and all further proceedings in this case, including the trial, order the entry of a final judgment, and conduct all post-judgment proceedings. Party Represented* Signatures Date ______________________________ _______________________________________ _____________________ ______________________________ _______________________________________ _____________________ ______________________________ _______________________________________ _____________________ *NOTE: THE UNITED STATES ATTORNEY FOR THE DISTRICT OF SOUTH CAROLINA BY STANDING MISCELLANEOUS FILING [3:04mc5005] HAS CONSENTED IN ALL SOCIAL SECURITY CASES TO DISPOSITION BY A UNITED STATES MAGISTRATE JUDGE.
ORDER OF REFERENCE
IT IS ORDERED that this case be referred to The Honorable __________________________, United States Magistrate Judge, to conduct all proceedings and order the entry of judgment in accordance with 28 U.S.C. § 636(c), Fed.R.Civ.P. 73. _____________________ Date ___________________________________________________________________ United States District Judge
NOTE: RETURN THIS FORM TO THE CLERK OF THE COURT ONLY IF ALL PARTIES HAVE CONSENTED ON THIS FORM TO THE EXERCISE OF JURISDICTION BY A UNITED STATES MAGISTRATE JUDGE.