Declaration of Financial Hardship

Legal Form Number4
CourtUnited States Court of Appeals For Veterans Claims
SectionCourt of Appeals for Veteran Claims
UNITED STATES COURT OF APPEALS FOR VETERANS CLAIMS
DECLARATION OF FINANCIAL HARDSHIP
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
($50.00) 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 Appellant/Petitioner, NOT 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.)
Form 4
(Rev. 06/22)
INSTRUCTIONS
To file this Declaration, either
(1) Email it to self-rep@uscourts.cavc.gov (if self-represented) or
esubmission@uscourts.cavc.gov (if represented), OR
(2) Fax it to (202) 501-5848, OR
(3) Send it to:
Clerk, US Court of Appeals for Veterans Claims
625 Indiana Avenue, NW, Suite 900
Washington, DC 20004-2950

To continue reading

Request your trial

VLEX uses login cookies to provide you with a better browsing experience. If you click on 'Accept' or continue browsing this site we consider that you accept our cookie policy. ACCEPT