S A M P L E F O R M A T

IN THE UNITED STATES DISTRICT COURT FOR THE

SOUTHERN DISTRICT OF MISSISSIPPI

DIVISION

,	)

)

Plaintiff(s),	)

vs.	)	Case No.

,	)

)

Defendant(s).	)

DECLARATION OF TECHNICAL DIFFICULTIES

Please take notice that was unable to file in a timely manner due to technical difficulties. The deadline for filing the was . The reason(s) that I was unable to file the in a timely manner and the good faith efforts I made prior to the filing deadline to both file in a timely manner and to inform the court and the other parties that I could not do so are set forth below.

[Statement of reasons and good faith efforts to file and to inform]

I declare under penalty of perjury that the foregoing is true and correct.

Respectfully submitted,

s/[Name of Password Registrant]

Name of Password Registrant

Address

City, State, Zip Code

Phone: XXX-XXX-XXXX

Fax:	XXX-XXX-XXXX

E-mail: XXX@XXX.XXX

FORM 5

***This Declaration (Form 5) should be submitted to the Clerk's Office conventionally, along with the document which could not be filed electronically. (Attach Declaration to that document as an Exhibit.) Filer will also need to present a Notice of Conventional Filing (Form 4) along with this Declaration.