U.S. District Court for the Northern District Of Illinois
Limited Attorney Appearance Form As
Settlement Assistance Program Counsel
Case Title: Case Number:
A limited appearance is hereby filed by the undersigned as settlement assistance
program counsel for (indicate the name of the party(s) being represented:
By filing this appearance, undersigned counsel represents that he/she has not entered
into, and will not seek to enter into, any agreement with the party for payment by the
party of fees and/or costs.
Attorney name (type or print):
Firm:
Street address:
City/State/Zip:
Bar ID Number: Telephone Number:
(See item 3 in instructions)
Email Address:
______________________________________________________________________
In order to appear before this Court an attorney must either be a member in good standing of this Court’s
general bar or be granted leave to appear pro hac vice as provided for by local rules 83.12 through 83.14.
I declare under penalty of perjury that the foregoing is true and correct. Under 28 U.S.C.§1746, this
statement under perjury has the same force and effect as a sworn statement made under oath.
Executed on
Attorney signature: S/
(Use electronic signature if the appearance form is filed electronically.)
Revised 8/10/2015
