USERRA Notification Form

• Legal Form Number: 06B
• Date: 01 July 2020
• Court: U.S. Court of Appeals — Federal Circuit
• Section: United States Court of Appeals for the Federal Circuit

FORM 6B. USERRA Notification FormForm 6B

July 2020

UNITED STATES COURT OF APPEALS

FOR THE FEDERAL CIRCUIT

USERRA NOTIFICATION FORM

Case Number:

Short Case Caption:

Petitioner:

Instructions:In a petition for review of a Merit Systems Protection Board decision,

a petitioner is not required to pay the docketing fee or costs if the petitioner is

claiming rights under the Uniformed Services Employment and Reemployment

Rights Act of 1994 (USERRA). See 38 U.S.C. §§ 4323, 4324. Please review the

below statements and signand submitthis form if the underlying appeal at the

Board involved a USERRA claimand you are pursuing your rights under USERRA

on appeal. The signed original shouldbe submitted within 14 days afterthe case is

docketed.

CERTIFICATION OF USERRA APPLICABILITY

1.I certify that the petitioner is not required to pay the docketing fee or costs in

this case because the underlying appeal at the Merit Systems Protection

Board involved a USERRA claimand I am pursuing my rights under

USERRA on appeal.

2.I declare under penalty of perjury under the laws of the United States that

the foregoing istrue and correct. See 28 U.S.C § 1746.

Date: _________________Signature:

Name:

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