UNITED STATES COURT OF APPEALS FOR VETERANS CLAIMS DECLARATION OF FINANCIAL HARDSHIP 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 (To be signed by Appellant, NOT Appellant's representative.) Date ******************************************* 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 Form 4 (Rev. 08/11) American LegalNet, Inc. www.FormsWorkFlow.com