FORM 6. Motion and Declaration for Leave to Proceed in Forma Pauperis Form 6 (p. 1) 

March 2023

UNITED STATES COURT OF APPEALS 

FOR THE FEDERAL CIRCUIT

MOTION AND DECLARATION FOR LEAVE TO 

PROCEED IN FORMA PAUPERIS

Case Number:

Short Case Caption:

Filer Name:

Instructions: If you would like to have the court consider waiving the docketing 

fee for your petition for review or notice of appeal, please complete and file this

form within 14 days after the date of docketing of your case. 

Complete all questions; if the answer to a question is 0, write in that response. In 

answering, identify only gross amounts (i.e., amounts before any deductions for 

taxes or otherwise). If you need more space to answer a question or to explain your 

answer, attach additional pages as needed. Failure to fully answer the questions 

may result in a denial of the motion.

DECLARATION

I hereby move for leave to proceed in forma pauperis, pursuant to 28 U.S.C. 

§ 1915, in this case and submit the following declaration in support thereof:

I, , am the Petitioner / Appellant in the aboveentitled case, and I declare that I am unable to pay the docketing fee for my petition 

/ appeal. The issues I intend to present for the court’s review are as follows: 
FORM 6. Motion and Declaration for Leave to Proceed in Forma Pauperis Form 6 (p. 2) 

March 2023

1. Pay/Wages Employer(s) (including selfemployment)

Gross Annual 

Pay/Wage

You $ 

Spouse $ 

2. Select whether you or your spouse have received income from the below 

sources over the past 12 months. If yes, on an attached sheet, identify each source 

of money and the gross amounts you or your spouse (1) have received over the past 

12 months and (2) expect to receive in the future.

☐ Yes ☐ No Income from real property

☐ Yes ☐ No Interest or dividends

☐ Yes ☐ No Alimony or child support

☐ Yes ☐ No Retirement (including social security, pension, or annuity)

☐ Yes ☐ No Disability or worker’s compensation

☐ Yes ☐ No Public Assistance or welfare (including unemployment)

☐ Yes ☐ No Inheritance or life insurance

☐ Yes ☐ No Gifts

☐ Yes ☐ No Other sources

3. Are you currently incarcerated?

☐ Yes ☐ No

If yes, you must (1) complete and submit Form 6A (Supplemental In Forma 

Pauperis Form for Prisoners Authorization) and (2) 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, attach one certified statement of each account.
FORM 6. Motion and Declaration for Leave to Proceed in Forma Pauperis Form 6 (p. 3)

March 2023

4. Describe and identify the value of any property, holding, or other thing of 

value owned by you or your spouse that exceeds $1,000 in current worth.

5. Identify the names (or initials, if under 18) of all persons who are dependent 

on you or your spouse for support, their relationship to you, and your contribution 

to their support.

6. Identify any debts, financial obligations, or monthly expenses for you and 

your spouse.
FORM 6. Motion and Declaration for Leave to Proceed in Forma Pauperis Form 6 (p. 4) 

March 2023

7. 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 below. 

8. Total amount of money you and your spouse have in cash, checking accounts, 

or savings accounts: $ __________________ 

9. Have you ever filed a motion for leave to proceed in forma pauperis in any 

other case in this court?

☐ Yes

☐ No 

If yes, identify the docket number(s): _________________________________________

DECLARATION UNDER PENALTY OF PERJURY

I declare under penalty of perjury under the laws of the United States that my 

answers on this form are true and correct. See 28 U.S.C § 1746. 

Date: _________________ Signature: 

 Name: