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Declaration of Financial Hardship 2020

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17 views1 page

Declaration of Financial Hardship 2020

Uploaded by

james425amos
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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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

(*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.)

INSTRUCTIONS

To file this Declaration, either

(1) Email it to [email protected] (if self-represented) or


[email protected] (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

Form 4
(Rev. 04/20)

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