FOR VETERANS CLAIMS APPENDIX OF FORMS FORM 1 UNITED STATES COURT OF APPEALS FOR VETERANS CLAIMS The following named appellant appeals to the Court from a final Board of Veterans' Appeals (BVA) decision. The Board's decision was dated Appellant's printed name Appellant's address VA claims file number Appellant's telephone number On a copy Signature of person filing this notice CERTIFICATE OF SERVICE of this Notice was mailed postage prepaid or served personally on General Counsel (027), Department of Veterans Affairs, 810 Vermont Avenue, NW, Washington, DC 20420. I declare under penalty of perjury, under the laws of the United States, that the foregoing is true and correct. Signature of person filing this notice Only if this Notice of Appeal is filed by a representative, check one of the following: [] My Notice of Appearance is attached. [ ] My representation is limited to the filing of this Notice of Appeal. FOR VETERANS CLAIMS FORM 2 IS-A-M-P-L-E] APPELLANT'S BRIEF UNITED STATES COURT OF VETERANS APPEALS 91-000 JOHN Q. VETERAN, Appellant, JESSE BROWN, FAIRS, Appellee. Oliver W. Counsel Lawyr & Lawyr 1111 J Street, NW Washington, DC 20000 (202) 555–1212 Attorney for Appellant Form 2 (Rev 4/93) FOR VETERANS CLAIMS V. FORM 3 UNITED STATES COURT OF APPEALS FOR VETERANS CLAIMS Secretary of Veterans Affairs. 1. Please enter my appearance for [] the appellant or petitioner [] admitted to practice before this Court. [] awaiting admission to practice; my application was submitted on (date) [] seeking to appear in this case only, under Rule 46(c); my motion is attached. 3. I am: [ ] the representative of record. I will accept service for the party and will inform all of the party's other representatives of the matters served upon me. [] not the representative of record, but am joining that representative. [] replacing the representative of record, who has been permitted to withdraw. 4. If I am representing the appellant, petitioner, or intervenor, my representation is: [ ] pursuant to the attached fee agreement. If it provides for direct payment out of past-due benefits under 38 U.S.C. § 5904, I have served a copy on counsel for the Secretary. [] without charge to the appellant, petitioner, or intervenor. I move for permission to appeal without paying the filing fee in this case and submit the following affidavit: I, am the appellant. I state that I am unable to pay the costs because of the hardship it will cause, and that I believe I am entitled to redress. 1. Are you now employed? a. If the answer is "yes", state the amount of your monthly salary or wages and the name and address of your employer. b. If the answer is "no", state the date of your last employment and the amount of your monthly salary or wages. 2. Within the past 12 months, have you received any income from a business, profession, other form of self-employment, rent payments, interest, dividends, retirement, annuity payments, alimony, welfare, social security, veterans benefits, disability compensation, workers' compensation, or any other source? If the answer is "yes", describe each source of income, and state the amount received from each during the past 12 months. (SEE OTHER SIDE) FOR VETERANS CLAIMS If 3. Do you have any cash or checking or savings accounts? the answer is "yes", state the total amount of cash and the average monthly balance in any account. 4. Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings and clothing)? If the answer is "yes", describe the property and state its approximate value. 5. List the persons whom you actually support and state your relationship to those persons. 6. Have you ever filed a motion in another case in this Court to appeal without payment of costs? If the answer is "yes", state the name and docket number of that case. 7. State any other circumstances that you want the Court to consider about your ability to pay costs: I state under penalty of perjury under the laws of the United States of America that the foregoing is true and correct. If you believe you are qualified to appeal without paying the filing fee, answer all of the questions on this form and send it (original only) to the Clerk with your Notice of Appeal. If you filed your Notice of Appeal by facsimile transmission, send this form to reach the Clerk within 14 days after you sent the facsimile Notice of Appeal. Form 4 (Rev 8/94) |