Form 4 "Declaration of Financial Hardship"

What Is Form 4?

This is a legal form that was released by the United States Court of Appeals for Veterans Claims on April 1, 2020 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2020;
  • The latest available edition released by the United States Court of Appeals for Veterans Claims;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 4 by clicking the link below or browse more documents and templates provided by the United States Court of Appeals for Veterans Claims.

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Download Form 4 "Declaration of Financial Hardship"

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UNITED STATES COURT OF APPEALS FOR VETERANS CLAIMS
D
F
H
ECLARATION OF
INANCIAL
ARDSHIP
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 self-rep@uscourts.cavc.gov (if self-represented) or
esubmission@uscourts.cavc.gov (if represented), OR
Fax it to (202) 501-5848, OR
(2)
(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)
UNITED STATES COURT OF APPEALS FOR VETERANS CLAIMS
D
F
H
ECLARATION OF
INANCIAL
ARDSHIP
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 self-rep@uscourts.cavc.gov (if self-represented) or
esubmission@uscourts.cavc.gov (if represented), OR
Fax it to (202) 501-5848, OR
(2)
(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)