Declaration of Financial Hardship (Appeal or Petition for Extraordinary Relief)

• Legal Form Number: 4a
• Court: United States Court of Appeals For Veterans Claims
• Section: Court of Appeals for Veteran Claims

Form 4a

02/2025

UNITED STATES COURT OF APPEALS FOR VETERANS CLAIMS

D

ECLARATION OF

F

INANCIAL

H

ARDSHIP –

R

ULE 24

(USE THIS FORM WHEN FILING AN APPEAL OR A PETITION FOR EXTRAORDINARY RELIEF.)

Docket No. (if assigned)

, Appellant/Petitioner,

v.

Secretary of Veterans Affairs , Appellee/Respondent.

I am the appellant/petitioner. I declare by my signature below that payment of the fifty dollar ($50)

filing fee referenced in Rule 3(f) and Rule 21(a) of the Court's Rules of Practice and Procedure

would be a financial hardship for me.

Pursuant to 28 U.S.C. § 1746, I certify, under penalty of perjury under the laws of the United

States of America, that the foregoing is true and correct.

Signature of Appellant/Petitioner* Date

Telephone number E-mail address

(*To be signed by the appellant/petitioner, NOT the appellant's/petitioner's representative. You may

electronically sign by typing "/s/" and then your name in the signature block above: for example,

/s/John Doe. If you are filing this form, do not pay the $50 filing fee.)

INSTRUCTIONS

To file this declaration, eithe

r

(1) Email it to self-rep@uscourts.cavc.gov (if self-represented) or

esubmission

@

uscourts.cavc.

g

ov

(

if re

p

resented

)

, O

R

(2) Fax it to (202) 501-5848, O

R

(3) Sen

d

it to:

Clerk, U.S. Court of Appeals for Veterans Claims

625 Indiana Avenue, NW, Suite 900

Washin

g

ton, DC 20004-2950