FORM 6. Motion and Declaration for Leave to Proceed in Forma Pauperis Form 6 Rev. 03/16 UNITED STATES COURT OF APPEALS FOR THE FEDERAL CIRCUIT v. No. Motion and Declaration for Leave to Proceed in Forma Pauperis INSTRUCTIONS: If you do not pay the fee, file this completed form with your petition for review or notice of appeal within 14 days of the date of docketing. Complete all questions in this application and then sign it. Do not leave any blanks; if the answer to a question is "0", "none", or "not applicable" (N/A), write in that response. If you need more space to answer a question or to explain your answer, attach a separate sheet of paper identified with your name, your case's docket number, and the question number. Failure to fully answer the questions may result in a denial of the motion. Petitioner/Appellant hereby moves for leave to proceed in forma pauperis, pursuant to 28 U.S.C. � 1915, in this case and submits the following declaration in support thereof: I, , am the Petitioner / Appellant in the above-entitled case. In support of my motion to proceed on appeal without being required to pay the docketing fee, I state that I am unable to pay the fee because of my poverty; that I believe that I am entitled to redress; and that the issues which I desire to present on appeal are the following: I further declare that the responses which I have made to the questions and instructions below relating to my ability to pay the docketing fee are true. 1. For both you and your spouse, estimate the average amount of money received from each of the following sources during the past 12 months. Adjust any amount that was received weekly, biweekly, quarterly, semiannually, or annually to show the monthly rate. Use gross amounts, that is, amounts before any deductions for taxes or otherwise. Income source Average monthly amount during the past 12 months You Employment Self-employment Income from real property (such as rental income) $ $ Amount expected next month You $ $ Spouse $ $ Spouse $ $ $ $ $ $ American LegalNet, Inc. www.FormsWorkFlow.com FORM 6. Motion and Declaration for Leave to Proceed in Forma Pauperis Form 6 Rev. 03/16 Income source Average monthly amount during the past 12 months You Spouse $ $ $ $ Amount expected next month You $ $ $ $ Spouse $ $ $ $ Interest and dividends Gifts Alimony Child support Retirement (such as social security, pensions, annuities, insurance) Disability (such as social security, insurance payments) Unemployment payments Public assistance (such as welfare) Other (specify) Total monthly income: $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 2. List your employment history for the past two years, most recent employer first. (Gross monthly pay is pay before taxes or other deductions). Employer Address Employment Dates Gross monthly pay $ $ $ 3. List your spouse's employment history for the past two years, most recent employer first. (Gross monthly pay is pay before taxes or other deductions.) Employment Dates Gross monthly pay Employer Address $ $ $ 4. Are you presently incarcerated? Yes No If yes, you must attach a statement certified by the appropriate institutional officer showing all receipts, expenditures, and balances during the last six months in your institutional accounts. If you have multiple accounts, perhaps because you have been in multiple institutions, attach one certified statement of each account. American LegalNet, Inc. www.FormsWorkFlow.com FORM 6. Motion and Declaration for Leave to Proceed in Forma Pauperis Form 6 Rev. 03/16 Below, state any 5. How much cash do you and your spouse have? $ money you or your spouse have in bank accounts or in any other financial institution. State the average monthly balance. Type of Account Amount you have Amount your spouse has Financial Institution $ $ $ $ 6. List the assets, and their values, which you own or your spouse owns. Do not list clothing and ordinary household furnishings. Home (Value) $ (Value) $ (Value) $ (Value) $ (Value) $ (Value) $ Other real estate (Value) $ (Value) $ (Value) $ Other assets Other assets Motor vehicle #1 Motor vehicle #2 (Value) $ (Value) $ (Value) $ Make, model & year: (Value) $ Make, model & year: Registration #: (Value) $ Registration #: 7. State every person, business, or organization owing you or your spouse money, and the amount owed: Person, business or organization owing you or your spouse money Amount owed to you Amount owed to your spouse $ $ $ $ $ $ 8. State the persons who rely on you or your spouse for support: Initials of Person Relationship Age American LegalNet, Inc. www.FormsWorkFlow.com FORM 6. Motion and Declaration for Leave to Proceed in Forma Pauperis Form 6 Rev. 03/16 9. Estimate the average monthly expenses of you and your family. Show separately the amounts paid by your spouse. Adjust any payments that are made weekly, biweekly, quarterly, semiannually, or annually to show the monthly rate. You Rent or home mortgage payment (include lot rented for mobile home) Are real estate taxes included? Is property insurance included? Utilities (electricity, heating fuel, water, sewer and telephone) Home maintenance (repairs and upkeep) Food Clothing Laundry and dry cleaning Medical and dental expenses Transportation (not including motor vehicle payments) Recreation, entertainment, newspapers, magazines, etc. Yes Yes $ $ Your Spouse No No $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Insurance (not deducted from wages or included in mortgage payments) Homeowner's or renter's Life Health Motor vehicle Other: Taxes (not deducted from wages or included in mortgage payments) (specify): $ $ $ $ $ $ $ $ $ $ $ $ American LegalNet, Inc. www.FormsWorkFlow.com FORM 6. Motion and Declaration for Leave to Proceed in Forma Pauperis Form 6 Rev. 03/16 Installment Payments Motor vehicle: Credit card (name): Department store (name): Other: Alimony, maintenance, and support paid to others $ $ $ $ $ You $ $ $ $ $ $ $ Your Spouse Regular expenses for operation of business, profession $ or farm (attach detailed statement) $ Other (specify): Total monthly expenses: $ $ 10. Do you expect any major changes to your monthly income or expenses or in your assets or liabilities during the next 12 months? If yes, describe on an attached sheet. Yes No 11. Have you paid, or will you be paying, an attorney any money for services in connection with this case, including the completion of this form? If yes, how much? $ Yes No If yes, state the attorney's name, address, and telephone