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e you have been in multiple institutions, attach one certified statement of each account. Form 6 104 5. How much cash do you and your spouse have? $______________ Below, state any money you or your spouse have in bank accounts or in any other financial institution. State the average monthly balance. Financial institution Type of account Amount you have Amount your spouse has ______________________ _________________ $_______________ $______________ ______________________ _________________ $_______________ $______________ 6. List the assets, and their values, which you own or your spouse owns. Do not list clothing and ordinary household furnishings. Home (Value) Other real estate (Value) Other assets (Value) ______________________ _________________________ _________________________ ______________________ _________________________ _________________________ ______________________ _________________________ _________________________ Other assets (Value) Motor vehicle #1 Motor vehicle #2 Make, model & year: Make, model & year: ______________________ _________________________ _________________________ Value: Value: ______________________ _________________________ _________________________ Registration #: Registration #: ______________________ _________________________ _________________________ 7. State every person, business, or organization owing you or your spouse money, and the amount owed: Person, business Amount owed to you Amount owed to your or organization owing spouse you or your spouse money _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ FORM 6. Motion and Declaration for Leave to Proceed in Forma Pauperis (continued) Form 6 105 FORM 6. Motion and Declaration for Leave to Proceed in Forma Pauperis (continued) 8. State the persons who rely on you or your spouse for support: Name Relationship Age ___________________________ _______________________ ______________________ ___________________________ _______________________ ______________________ ___________________________ _______________________ ______________________ 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 Your spouse Rent or home mortgage payment $__________ $__________ (include lot rented for mobile home) Are real estate taxes included? ___Yes ___No Is property insurance included? ___Yes ___No 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. $__________ $__________ 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): __________________ $__________ $__________ Form 6 106 FORM 6. Motion and Declaration for Leave to Proceed in Forma Pauperis (continued) You Your spouse Installment payments Motor vehicle $__________ $__________ Credit card (name): ______________ $__________ $__________ Department store (name): ______________ $__________ $__________ Other: _____________________ $__________ $__________ Alimony, maintenance, and support paid to others $__________ $__________ 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? ___Yes ___No If yes, describe on an attached sheet. 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? ___Yes ___No If yes, how much? $_______ If yes, state the attorney’s name, address, and telephone number: __________________________________________________________________ __________________________________________________________________ 12. Have you paid, or will you be paying, anyone other than an attorney (such as a paralegal or a typist) any money for services in connection with this case, including the completion of this form? ___Yes ___No If yes, how much? $_______ If yes, state the person’s name, address, and telephone number: __________________________________________________________________ __________________________________________________________________ 13. Provide any other information that will help explain why you cannot pay the docketing fees for your appeal or petition for review. __________________________________________________________________ __________________________________________________________________ Form 6 107 FORM 6. Motion and Declaration for Leave to Proceed in Forma Pauperis (continued) 14. Have you ever filed a motion for leave to proceed in forma pauperis in any other case in this court? ___Yes ___No If yes, state the name and docket number of that case. __________________________________________________________________ 15. State the address of your legal residence: __________________________________________________________________ __________________________________________________________________ Your daytime phone number: ( ) ____________________________________ Your social security number: __________________________________________ Your age: ________________ Your years of schooling: ___________________ __________________________________________________________________ You must sign and date the declaration under penalty of perjury. DECLARATION UNDER PENALTY OF PERJURY I declare under penalty of perjury, under the laws of the United States, that my answer on this form are true and correct. _____________________ _________________________________________ Date Petitioner’s/Appellant’s signature ORDER OF THE COURT The motion to proceed in forma The motion to proceed in forma pauperis pauperis is DENIED. The docketing is GRANTED. Let the applicant proceed fee must be paid within 14 days. without prepayment of the docketing fee. _____________________ __________ _____________________ _____________ Circuit Judge Date Circuit Judge or Clerk Date Form 6 108 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 $250 or $255. 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 Signature You must sign and date above. You must also complete 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? Yes No If so, how many times? Were any of the actions or appeals dismissed because they were frivolous, malicious, or failed to state a claim upon which relief may be granted? Yes No If so, 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. Date Petitioner’s Signature FORM 6A. Supplemental in Forma Pauperis Form for Prisoners Form 6A 109 FORM 7. Appeal Information Sheet FEDERAL CIRCUIT APPEAL INFORMATION SHEET ___ United States District Court for the ____________________________________ ___ United States Court of International Trade ___ United States Court of Federal Claims ___ United States Court of Appeals for Veterans Claims Type of case: ________________________________________ _____________________ v. _____________________ (List all parties. Use an asterisk to indicate dismissed or withdrawn parties. Use a separate sheet if needed. Explain any discrepancy with the caption used on the judgment, order, or opinion.) Docket No. _____________________ Date of Judgment or Order __________________ Cross or related appeal? __________ Date of Notice of Appeal __________________ Appellant is: _____ Plaintiff _____Defendant _____Other (explain)_________________ FEES: Court of Appeals docket fee paid? _____Yes _____No U.S. Appeal? _____Yes _____No In forma pauperis? _____Yes _____No Is this matter under seal? _____Yes _____No COUNSEL: (List name, firm, address, and telephone of lead counsel for each party. Indicate party represented. Use separate sheet if needed.) ____________________________ _______________________________________________ ____________________________ _______________________________________________ ____________________________ _______________________________________________ ____________________________ _______________________________________________ COURT REPORTER: (Name and telephone): _______________________________________ IMPORTANT: Attach a copy of the judgment or order appealed from and any supporting opinion or memorandum. Forward together with a copy of the notice of appeal and certified docket entries. Clerk of Court United States Court of Appeals for the Federal Circuit 717 Madison Place, NW Washington, DC 20439 Form 7 110 FORM 8. Entry of Appearance UNITED STATES COURT OF APPEALS FOR THE FEDERAL CIRCUIT ____________________________ v. ____________________________ No. _______ ENTRY OF APPEARANCE (INSTRUCTIONS: Counsel should refer to Fed. Cir. R. 47.3. Pro se petitioners and appellants should read paragraphs 1 and 18 of the Guide for Pro Se Petitioners and Appellants. File this form with the clerk and serve a copy of it on the principal attorney for each party.) Please enter my appearance (select one): _____Pro Se _____As counsel for: _______________________________ Name of party I am, or the party I represent is (select one): _____Petitioner _____Respondent _____Amicus curiae _____Cross Appellant _____Appellant _____Appellee _____Intervenor As amicus curiae or intervenor, this party supports (select one): _____Petitioner or appellant _____Respondent or appellee My address and telephone are: Name: _________________________________________________ Law firm: _________________________________________________ Address: _________________________________________________ City, State and ZIP: _________________________________________________ Telephone: _________________________________________________ Fax #: _________________________________________________ E-mail address: _________________________________________________ Statement to be completed by counsel only (select one): _____ I am the principal attorney for this party in this case and will accept all service for the party. I agree to inform all other counsel in this case of the matters served upon me. _____ I am replacing ______________ as the principal attorney who will/will not remain on the case. [Government attorneys only.] _____ I am not the principal attorney for this party in this case. Date admitted to Federal Circuit bar (counsel only): ______________ This is my first appearance before the United States Court of Appeals for the Federal Circuit (counsel only): _____Yes _____No _____A courtroom accessible to the handicapped is required if oral argument is scheduled. ______________ ___________________________________ Date Signature of pro se or counsel Form 8 111 FORM 9. Certificate of Interest UNITED STATES COURT OF APPEALS FOR THE FEDERAL CIRCUIT ____________________________ v. ____________________________ No. _______ CERTIFICATE OF INTEREST Counsel for the (petitioner) (appellant) (respondent) (appellee) (amicus) (name of party) _______________________ certifies the following (use “None” if applicable; use extra sheets if necessary): 1. The full name of every party or amicus represented by me is: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 2. The name of the real party in interest (if the party named in the caption is not the real party in interest) represented by me is: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 3. All parent corporations and any publicly held companies that own 10 percent or more of the stock of the party or amicus curiae represented by me are: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 4. ? There is no such corporation as listed in paragraph 3. 5. The names of all law firms and the partners or associates that appeared for the party or amicus now represented by me in the trial court or agency or are expected to appear in this court are: _____________________________________________________________________________ _____________________________________________________________________________ _____________________ _______________________________ Date Signature of counsel _______________________________ Printed name of counsel Form 9 112 FORM 10. Statement Concerning Discrimination UNITED STATES COURT OF APPEALS FOR THE FEDERAL CIRCUIT ____________________________ v. ____________________________ No. _______ PETITIONER’S FED. CIR. R. 15(c) STATEMENT CONCERNING DISCRIMINATION INSTRUCTIONS: Select only one of the following statements. Do not alter or add to any of the statements. _____ (1) No claim of discrimination by reason of race, sex, age, national origin, or handicapped condition has been or will be made in this case. _____ (2) Any claim of discrimination by reason of race, sex, age, national origin, or handicapped condition raised before the employing agency or the Merit Systems Protection Board or arbitrator has been abandoned or will not be raised or continued in this or any other court. _____ (3) The petition seeks review only of the Merit Systems Protection Board’s or arbitrator’s dismissal of the case for lack of jurisdiction or for untimeliness. _____ (4) The case involves an application to the Office of Personnel Management for benefits. _____ (5) The case was transferred to this court from a district court and I continue to contest the transfer. Also, answer the following: Have you filed a discrimination case in a United States district court concerning the same matter? _____Yes _____No In the Equal Employment Opportunity Commission? _____Yes _____No If so, identify each case. Use extra sheets if needed. ____________________ __________________________________________ Date Petitioner’s signature Mail this form with the petition for review or within 14 days of the date of docketing of the petition for review to: Clerk of Court United States Court of Appeals for the Federal Circuit 717 Madison Place, NW Washington, DC 20439 Form 10 113 FORM 11. Informal Brief (MSPB or Arbitrator Cases) UNITED STATES COURT OF APPEALS FOR THE FEDERAL CIRCUIT ____________________________ v. ____________________________ No. _______ INFORMAL BRIEF OF PETITIONER Read the Guide for Pro Se Petitioners and Appellants before completing this form. Attach a copy of the initial and final decision or order of the Merit Systems Protection Board or arbitrator. Answer the following questions as best you can. Your answers should refer to the decision or order you are appealing where possible. Use extra sheets if needed. 1. Have you ever had another case in this court? _____Yes _____No In a United States district court? _____Yes _____No In the Equal Employment Opportunity Commission? _____Yes _____N

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