Declaration of Financial Hardship (Request for Class Certification and Class Action)

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

Form 4b

02/2025

UNITED STATES COURT OF APPEALS FOR VETERANS CLAIMS

DECLARATION OF FINANCIAL HARDSHIP – RULE 24

(USE THIS FORM WHEN FILING A REQUEST FOR CLASS CERTIFICATION.)

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 four hundred dollar

($400) filing fee referenced in Rule 22(e) of the Court's Rules of Practice and Procedure for filing a

request for class certification 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 $400 filing fee.)

INSTRUCTIONS

To file this declaration, either

(1) Email it to esubmission@uscourts.cavc.gov, or if the corresponding

appeal or petition is pending, file it in accordance with the Court's E-filing

Rules, OR

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

(3) Send it to

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

625 Indiana Avenue, NW, Suite 900

Washin

g

ton, DC 20004-2950