FORM 6A. Supplemental in Forma Pauperis Form for Prisoners Form 6A Rev. 03/16 UNITED STATES COURT OF APPEALS FOR THE FEDERAL CIRCUIT SUPPLEMENTAL IN FORMA PAUPERIS FORM FOR PRISONERS AUTHORIZATION FORM I, , request and authorize the agency holding me in custody, to send to the Clerk of the United States Court of Appeals for the Federal Circuit a certified copy of the statement for the past six months of my trust fund account (or institutional equivalent) at the institution where I am incarcerated. I further request and authorize the agency holding me in custody to calculate and disburse funds from my trust fund account (or institutional equivalent) in the amounts specified by 28 U.S.C. § 1915(b). This authorization is furnished in connection with an appeal, and I understand that the total appellate filing fees for which I am obligated are $500 or $505. I also understand that these fees will be debited from my account regardless of the outcome of my appeal. This authorization shall apply to any other agency into whose custody I may be transferred. Date Petitioner's/Appellant's Signature You must sign and date above. You must also complete both the following Disclosure and sign and date the Declaration Under Penalty of Perjury below. DISCLOSURE OF PRIOR FEDERAL ACTIONS If you are presently incarcerated, have you ever before brought an action or appeal in a federal court while you were incarcerated or detained? If yes, how many times? Were any of the actions or appeals dismissed because they were frivolous, malicious, or failed to state a YES NO claim upon which relief may be granted? If yes, how many of them? DECLARATION UNDER PENALTY OF PERJURY I declare under penalty of perjury, under the laws of the United States, that the foregoing is true and correct. YES NO Date cc: Petitioner's/Appellant's Signature American LegalNet, Inc. www.FormsWorkFlow.com