Declaration of Financial Hardship

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