Consent Form

UNITED STATES DISTRICT COURT DISTRICT OF CONNECTICUT UNITED STATES OF AMERICA v. : : : : : CRIM.NO.: CONSENT FORM The defendant, , hereby consents to have a United States Magistrate Judge hear the application and to administer the allocution pursuant to F.R. Crim. P., Rule 11. CONSENTED TO: DEFENDANT: Date ATTORNEY FOR DEFENDANT: Date UNITED STATES ATTORNEY BY A.U.S.A.: Date Rev. 5/3/2011 American LegalNet, Inc. www.FormsWorkFlow.com