Motion and Declaration for Leave to Proceed in Forma Pauperis

• Legal Form Number: 06
• Date: 01 March 2023
• Court: U.S. Court of Appeals — Federal Circuit
• Section: United States Court of Appeals for the Federal Circuit

FORM 6. Motion and Declaration for Leave to Proceed in Forma Pauperis Form 6 (p. 1)

March 2023

UNITED STATES COURT OF APPEALS

FOR THE FEDERAL CIRCUIT

MOTION AND DECLARATION FOR LEAVE TO

PROCEED IN FORMA PAUPERIS

Case Number:

Short Case Caption:

Filer Name:

Instructions: If you would like to have the court consider waiving the docketing

fee for your petition for review or notice of appeal, please complete and file this

form within 14 days after the date of docketing of your case.

Complete all questions; if the answer to a question is 0, write in that response. In

answering, identify only

gross amounts (i.e., amounts before any deductions for

taxes or otherwise). If you need more space to answer a question or to explain your

answer, attach additional pages as needed. Failure to fully answer the questions

may result in a denial of the motion.

DECLARATION

I hereby move for leave to proceed in forma pauperis, pursuant to 28 U.S.C.

§1915, in this case and submit the following declaration in support thereof:

I, , am the Petitioner / Appellant in the above-

entitled case, and I declare that I am unable to pay the docketing fee for my petition

/ appeal. The issues I intend to present for the court’s review are as follows: