Supplemental in Forma Pauperis Form for Prisoners

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

FORM 6A. Supplemental in Forma Pauperis Form for PrisonersForm 6A(p. 1)

December2023

UNITED STATES COURT OF APPEALS

FOR THE FEDERAL CIRCUIT

SUPPLEMENTAL IN FORMA PAUPERIS FORM FOR PRISONERS

AUTHORIZATION FORM

Case Number:

Short Case Caption:

I request and authorize the agency holding mein custody, to send to the

Clerk of the United States Court of Appeals for the Federal Circuit a certified copy

of the statement for the past six months of my trust fund account (or institutional

equivalent) at the institution where I amincarcerated.

I further request and authorize the agencyholding mein custody to calculate

and disburse funds from my trust fund account (or institutionalequivalent) in the

amounts specified by28 U.S.C. §1915(b).This authorizationis furnished in

connection withan appeal, and I understand that the total appellate filing fee for

which I am obligatedis$600 or $605.

I also understand that these fees will be debited from my account regardless

of the outcome of my appeal. This authorization applies to any other agency into

whose custody I maybe transferred.

Date: _________________Signature:

Name:

DISCLOSURE OF PRIOR FEDERAL ACTIONS

1. Have you ever before brought an action or appeal in a federal court while you

were incarcerated or detained?☐Yes ☐ No

If yes, how many times?

2. Were any of the actions or appeals dismissed because they were frivolous,

malicious, or failed to state a claim upon which relief may be granted?

☐Yes☐No

If yes, how many of them?