Rules of Practice and Procedure effective September 15, 2011 - page 75

D
UNITED STATES COURT OF APPEALS FOR VETERANS CLAIMS
D
ECLARATION OF
F
INANCIAL
H
ARDSHIP
Docket No.________
, 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 required by Rule 3(f) or 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
(To be signed by Appellant, NOT Appellant's Representative.)
*******************************************
Form 4
(Rev. 08/11)
INSTRUCTIONS
Send this Declaration (original only) to:
Clerk, U.S. Court of Appeals for Veterans Claims
625 Indiana Avenue, NW, Suite 900
Washington, DC 20004-2950
OR
Fax (202) 501-5848
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