A Guide for Self-

Representation

United States Court

of Federal Claims
Updated June 2021

0
 Table of Contents
Introductory Comments by Clerk of Court .............................................................. page 1

Section 1: Before You File Your Case ................................................................... page 2-3

Section 2: Start to Finish: The Civil Case Process ................................................. pages 4-6
How to File Your Complaint ............................................................... pages 4-5
Steps in the Civil Case Process ................................................................. page 6

Section 3: How Can We Help?................................................................................. page 7

Section 4: Other Information ............................................................................. pages 8-10

Certificate of Service Rule........................................................................ page 8
Initial Filing Checklist ............................................................................. page 9
U.S. Court of Federal Claims Fee Schedule............................................ page 10

Appendix .............................................................................................................. A1-A13

Glossary of Terms .......................................................................................... A1-A2
Civil Cover Sheet ................................................................................................. A3
Nature of Suit....................................................................................................... A4
Agency Codes ...................................................................................................... A5
Pro Se Complaint Form ................................................................................... A6-A8
Application to Proceed In Forma Pauperis ..................................................... A9-A10
Prisoner Authorization Form .............................................................................. A11
Certificate of Service........................................................................................... A12
Notice of Change of Address .............................................................................. A13
Notice of Appeal Form ....................................................................................... A14
Introductory Comments by the
Clerk of Court
Welcome to the United States Court of Federal Claims.

Representing yourself in a lawsuit can be complicated, time consuming, and costly. This
guide is intended to assist pro se plaintiffs in filing their cases and in understanding the rules
and procedures for the U.S. Court of Federal Claims. Please note, however, this guide is not
intended to be used as a surrogate for the court’s rules. Failure to comply with court rules
and procedures can mean losing your case. We encourage you not only to read this guide
but also to visit the court’s website at www.uscfc.uscourts.gov for additional information
and resources.

After reading this guide, if you still have questions about filing a case in this court, please
contact the clerk’s office at (202) 357-6406. Keep in mind that clerk’s office staff can help
you with court procedures, but they cannot give you any legal advice. For example, they
cannot help you decide whether to file a case in this court or, once filed, what to do in your
case. They also cannot explain a law or advise you on what words to use in your court
documents.

We welcome any comments or suggestions for improving this guide. Please forward your
comments to: Office of the Clerk of Court, U.S. Court of Federal Claims, 717 Madison
Place, NW, Washington, DC 20439.

Lisa L. Reyes
Clerk of Court

1
Section 1

Before You File Your Case

The U.S. Court of Federal Claims has limited, nationwide jurisdiction and hears monetary
claims against the United States Government. It is not a district court; the court has its own
separate jurisdiction, rules, and procedures. Before you file your case in the U.S. Court of
Federal Claims, you should ask yourself the following questions:

Are you in the right court?

You should make sure that you are filing your case with the correct court. If the court lacks
jurisdiction over your claim, your claim will be dismissed. This can be especially important
if your claim has a “statute of limitations.” Filing in the wrong court might affect whether or
not your claim is filed prior to the deadline for doing so.
 Types of cases filed in this court include:
- Federal tax disputes
- Taking of private property
- Military and civilian pay
- Breaches of contracts involving the federal government
- Patent and copyright infringement by the federal government
- Bid protests
- Vaccine injuries1 (cases filed under the National Vaccine Injury Compensation Program)

Is your complaint timely?

A statute of limitations is the period of time set by law within which a claim must be filed.
This period of time ordinarily begins when the injury occurs or when a right has been
violated. If you fail to file your complaint within the time allotted by the statute, your case
will be dismissed.

NOTE: The clerk’s office is unable to answer specific questions about your statute of
limitations. It is your responsibility to keep track of and meet your deadlines.

Additional information for prisoner-plaintiffs to consider:

 A prisoner-plaintiff wishing to proceed without prepayment of the required filing fees
may file an Application to Proceed In Forma Pauperis (IFP).

1
The information in this guide covers general jurisdiction complaints filed against the United States in the
U.S. Court of Federal Claims. If you wish to obtain information about vaccine claims in this court, you should
contact the clerk’s office and request a copy of the Guidelines for Practice Under the National Vaccine Injury
Compensation Program.
2
 - Along with the IFP application, a prisoner must also submit a certified copy of
their trust fund account statement for the 6-month period immediately preceding
the filing of the complaint as well as a signed copy of the court’s Prisoner
Authorization form (see A10).
- Failure to provide this information may result in the dismissal of your case.

 Upon approval of your IFP application, a prisoner-plaintiff must pay an “initial partial
filing fee” and subsequent partial payments thereafter until the filing fee is paid in full
pursuant to 28 U.S.C. § 1915(b).

PLEASE NOTE: All prisoner‐plaintiffs are obligated to pay the filing fee even if
their complaint is ultimately dismissed for lack of subject‐matter jurisdiction.
Therefore, it is important to review this court’s jurisdictional requirements prior
to filing a complaint.

Three Strikes Rule: Prisoner-plaintiffs who, while incarcerated, have filed three or more
complaints in federal court that were dismissed for frivolousness, maliciousness, or
failure to state a claim cannot proceed in forma pauperis and must prepay the required
filing fee, unless the prisoner-plaintiff meets a statutory exception under 28 U.S.C.
§ 1915(g).

3
Section 2

Start to Finish: The Civil

Case Process
Fig. 1
How to File Your Complaint
Fig. 1 is an image of the model pro se complaint form
that is provided in the appendix of this guide (see A5-
A7). If you require additional space to answer a
particular question, please finish your response on
additional paper, making sure that each answer is
properly numbered.
-OR-
If you do not wish to use the provided pro se complaint
form, please use the following information to help you
draft your complaint.

Step 1-Format Your Complaint

Complaints may be typed or handwritten. If
handwritten, the writing must be legible. Use Fig. 1 as
a model to ensure compliance with the format
requirements of the U.S. Court of Federal Claims.
 Court Title: “The United States Court of
Federal Claims” must be written at the top of
your complaint, as well as on all future filings.
 Case Number & Judge: Leave this area blank. Once your case has been opened, the
court will inform you of your case number and judge assignment by mail. You must
include the case number and judge’s name on all future filings.
 Title of Document: You must indicate what you are filing by including a title at the
beginning of the document.

Step 2-Draft Your Complaint

Your complaint should be a summary of why you are filing your case in the U.S. Court of
Federal Claims, why this court has legal jurisdiction over your case, the statement of facts,
and the relief that you are requesting. The following topics should be covered in your
complaint:
 Jurisdiction: Explain why the U.S. Court of Federal Claims has jurisdiction over
your case.
 Parties: Identify the parties in your case.
4
 - REMEMBER: In this court, the defendant is always the United States, which
includes ALL federal agencies.

 Statement of Facts: Explain the relevant facts of your case.

 Claims: List your legal claims.

- This is the section in which you allege that the defendant violated laws or legal
obligations that entitle you to monetary relief. You must identify the source of
that law or legal obligation.

 Request for Relief: Explain what you would like the court to do.
Fig. 2
 Exhibits: If you choose to include exhibits, they
should be numbered in sequential order. Forms To Submit With Your
Complaint
Step 3-Submit Your Complaint 
Once you have drafted your complaint, you must submit All of these forms are included in the appendix of this
the documents to the clerk’s office either by mail or in guide as well as on the court’s website.
person. Fig. 2 provides a quick description of the 
required forms, as well as the number of copies you will Complaint: 1 original + 2 copies
need to provide of each. An initial filing checklist can Cover Sheet: a form that asks you questions
also be found on page 9. about the nature of your case.
(Required: 1 original)
If you wish to file your complaint by hand, deliver your Required Filing Fee: (See Schedule of Fees on
documents to the clerk’s office in Room 103 of the page 10)
Howard T. Markey National Courts Building at 717 - OR -
Madison Place, NW, which is across from the White
House on the east side of Lafayette Park. If you prefer to In Forma Pauperis Application: a request to
submit your complaint (and other documents) by mail, waive prepayment of the filing fee. This form
all documents should be mailed to: must be submitted with your complaint and
is only for those who cannot afford the fee.
Clerk of Court You will answer questions about your income
U.S. Court of Federal Claims and employment status that will help the
717 Madison Place, NW court make its decision to grant or deny the
Washington, DC 20439 application.
(Required: 1 original + 2 copies)
Along with your complaint and required copies, you
must submit a Civil Cover Sheet. This form is available PLEASE NOTE: Clerk’s office staff cannot
on the court’s website at www.uscfc.uscourts.gov as well help you write your complaint or tell you
as in the appendix of this guide (see A3). how to complete the required forms.

When filing your complaint, you must also include either the filing fee (see Schedule of Fees
on page 10) or an Application to Proceed In Forma Pauperis (IFP). This form is available on
the court’s website as well as in the appendix of this guide (see A8-A9). Only those who
cannot afford the filing fee should apply for IFP status. If your IFP application is denied,
you must promptly pay the filing fee or your case will be dismissed.

5
 The Civil Case Process

Please note that this flowchart is a generic example of how your case may proceed. Individual cases may vary. Also note that the
court may issue a decision at any time and deadlines may be extended or altered by court order.

6
Section 3

Clerk’s Office: How Can We

Help?
WE ARE HAPPY TO HELP YOU IF WE CAN. WE ARE NOT, HOWEVER,
PERMITTED TO PROVIDE LEGAL ADVICE AND WE MUST PROVIDE THE
SAME INFORMATION TO EVERYONE.

Below are some examples of things that clerk’s office staff can and cannot do for you.

We can explain and answer questions We cannot tell you whether or not you
about how the court works. should file a case in this
court.
We can give you general information
about court rules, procedures, We cannot give you an opinion about
and practices. what will happen if you
bring your case to court.
We can provide court schedules.
We cannot tell you what words to use in
We can provide you with information your court papers.
about your particular case.
We cannot talk to the judge for you or
We can provide you with available court let you talk to the judge
forms and instructions. outside of a court
proceeding.
We can answer questions about publicly
available court deadlines. We cannot tell you what to say in court.

We cannot provide you with legal

advice.

We cannot tell you what you should do

next in your case.

We cannot compute deadlines in your

case.

Since clerk’s office staff may not know the answers to all of your questions about court
rules, procedures, and practices, and because we do not want to give you incorrect
information, we have been instructed not to answer questions if we do not know the correct
answers or if the information is not publicly available. For additional information, please
contact a lawyer or your local law library, or visit the court’s website at
www.uscfc.uscourts.gov.

7
Section 4

Other Information
Certificate of Service Rule
All documents filed after the complaint MUST include a Certificate of Service stating that you
“served” a copy of the document on the attorney representing the United States and on any
other parties in the case (or on their attorney if they are represented by counsel) and the date
the document was served. It is important that you include a Certificate of Service with every
filing; failure to do so may hinder the filing of your documents. A fillable Certificate is
included in the appendix of this guide (see A11). Documents filed do not need to be notarized
or sent via certified mail.

Change of Address
If your address changes while you have a case before the court, you must PROMPTLY file
and serve a written notice of the change of address. If you do not notify the court and opposing
counsel with a written notice, service of future filings will be made to your old address and
may prevent you from receiving the documents, possibly causing you to miss filing deadlines.
Your case may be dismissed if you fail to respond to court orders or meet deadlines for
required filings. A sample of this form can be found in the appendix of this guide (see A12).

Format of Documents
All documents sent to the court should bear the court’s name, correct docket number, and the
name of the presiding judge to whom your case is assigned. The case number and judge
assignment will be provided to you by the court once your complaint has been filed. Your
name, address, and telephone number are also required on all pleadings and papers.
All documents must be submitted for filing on standard 8½-by-11-inch white paper and
comply with the format requirements of Rule 5.5. Submissions that do not conform to the
court’s rules, e.g., books, laminated documents, personal items, or unbound papers, as well as
excessively voluminous documents, will be forwarded to an assigned judge for acceptance or
rejection.

Protecting Personal Information

If you are filing a document that contains personal identifiers such as your social security
number, it is VERY important that you either redact (black out) the specific information or
clearly indicate that your document should be filed under seal. It is the sole responsibility of
the filing party to protect personal information included in a filing; the clerk’s office will not
review filings to ensure that information has been adequately protected. See Rule 5.2(a) and
(h).

Copies of Documents
You must file an original and 2 copies of all filings. If you would like the court to return to you
a filed, date stamped copy of any document, you must provide an additional copy of the
document and a self-addressed, stamped envelope when you file the document with the court.
8
Notice of Appeal
If you wish to appeal a judge’s final decision, you must submit a notice of appeal, which can
be found in the appendix of this guide (see A13). The filing of the notice begins the appeal
process and your case will be sent to the U.S. Court of Appeals for the Federal Circuit. Once
your case is appealed, all future filings should be sent to the appellate court. If you did not
receive a waiver for the initial filing fee, you will also need to provide a check made out to:
Clerk, U.S. Court of Federal Claims (see page 10 for appropriate fee).

Operation of the Clerk’s Office

 General Information:
- The clerk’s office is open for business between the hours of 8:30 a.m. and 4:30 p.m.,2
Monday through Friday (except federal holidays). You may contact the clerk’s office by
telephone at (202) 357-6406 during normal business hours.
 Court’s Address:
- The United States Court of Federal Claims clerk’s office is located in Room 103 of the
Howard T. Markey National Courts Building, 717 Madison Place, NW Washington,
DC 20439.

Where to Obtain our Local Rules

The United States Court of Federal Claims Rules can be obtained by calling the clerk’s office
at (202) 357-6406, visiting the court’s website www.cofc.uscourts.gov, or by clicking on the
following link: U.S. Court of Federal Claims Current Rules.

Checklist

Initial Filing Checklist

□ I have researched the court’s jurisdiction and have determined that I am filing in the
appropriate court.
□ If I have a statute of limitations, I have submitted my complaint before the statute has run
out.
□ I have provided an original and two copies of my complaint.
□ I have provided a completed Civil Cover Sheet with my current contact information.
□ I have submitted the appropriate filing fee OR a completed Application to Proceed In Forma
Pauperis.
□ If I am a prisoner, I have also included the Prisoner Authorization form and a certified copy
of my trust fund account statement for the last six (6) months.

2
New court hours effective August 1, 2016.
9
 United States Court of Federal Claims
Schedule of Fees3
(effective May 26, 2021)

All fees are payable to the Clerk, U.S. Court of Federal Claims,
by cash, check, or money order.4

FILING FEES
Complaint/Petition $402.005
Prisoner Complaint with IFP Motion $350.006
Notice of Appeal $505.00
Petition to Perpetuate Testimony Under Rule 27(a) $49.00

COPY FEES
Paper Documents $0.50/page
Certification of Document or Paper (in addition to cost
$11.00
of copy)
Exemplified Copy of Document or Paper $23.00
Audio Recording of Court Proceeding $32.00/disk
Copy of Document in Electronic Form $31.007

MISCELLANEOUS FEES
Payment Returned or Denied for Insufficient Funds $53.00
$64.00/first box; $39.00/each
Record Retrieval from Archives
additional box
Electronic Record Retrieval (SmartScan) $19.90 plus $0.65/page8
Search of Court Records $31.00/name or item
Apostille $47.00

3
This is an abbreviated fee schedule, listing those fees that commonly pertain to pro se litigation. For a complete
list of court fees, please visit the court’s official website at [email protected].
4
If electronically filing a complaint, petition, or notice of appeal using the court’s electronic
management/electronic case files (CM/ECF) system, the filer must pay the filing fee by credit card in CM/ECF.
5
Effective December 1, 2020, the $402.00 filing fee includes a $52.00 general administrative fee. Pursuant to 28
U.S.C. § 1915, the $52.00 administrative fee is waived for prisoner-plaintiffs granted in forma pauperis (IFP)
status and all filing fees are waived for non-prisoner plaintiffs granted IFP status.
6
All prisoners are required to pay the filing fee. If proceeding in forma pauperis, that fee is $350. If the IFP motion
is denied, the fee is $402.
7
Effective September 1, 2018, this fee applies when the court provides a copy of a record in electronic form, that
record is not stored in the court’s CM/ECF system, and no separate fee for a copy of a recording of a court
proceeding applies.
8
Effective June 1, 2016, this service includes a $10 judiciary administrative fee and two additional Federal Record
Center (FRC) fees: a $9.90 flat rate fee to pull and refile the record(s) and a $0.65 per page fee. The FRC fees are
subject to change in accordance with the Inter-Agency Agreement between the Administrative Office of the
United States Courts and the FRC.

10
Section 6

Glossary of Terms
Affidavit: A sworn, written statement plaintiff may be able to refile or reopen the
made under oath, affirming that all case with modifications.
information is true.
Docket: The summary of activity in a
Amendment: A formal revision made to a certain case containing a list of the parties,
legal document. their attorneys, and all filings.

Answer: A formal written statement In Forma Pauperis: Permission given by

made by the defendant which answers the court for an individual to file a case
each allegation contained in the complaint without prepayment of the required court
and sets forth the defendant’s defenses and fees because the person is unable to pay
counterclaims. them. Often abbreviated as IFP.

Clerk of Court: An officer appointed by Judgment: The final action by the court
the court to oversee the court’s that is entered on the docket. The
administration. The Clerk of Court has judgment officially closes the case.
appointed deputy clerks who are available
to provide case specific information. Jurisdiction: The legal authority of a
court to hear and decide a case.
Complaint: A written statement filed by
the plaintiff that opens a case, identifies Motion: A formal request to the court to
the plaintiff’s claims, and states what relief issue an order. For example, a party may
the plaintiff is seeking. file a motion asking the court to extend
the time for filing a response. The motion
Cross-motion: A motion in general is a must include reasons for the request.
request to the court to issue an order. A
cross-motion is a request to the court to Notice of Appeal: A document filed that
deny the first motion and instead grant an informs the court that a judgment or order
opposing one. is being appealed to the U.S. Court of
Appeals for the Federal Circuit. The filing
Defendant: The party against whom the of a notice of appeal begins the appeal
complaint is made. In the U.S. Court of process and must be accompanied by a
Federal Claims, the defendant is always certificate of service.
the United States.
Notice of Appearance: A document filed
Dismissal: When a judge dismisses a by an attorney at the U.S. Department of
case, the judge essentially ends the case Justice identifying who will be
without a trial. If the dismissal is “with representing the United States in a case.
prejudice,” the plaintiff cannot refile it. If Once an appearance is filed, pro se litigants
the dismissal is “without prejudice,” the must serve all future filings on the

A‐1
attorney listed on the notice of Statute of Limitations: A law that sets a
appearance. time period within which a complaint
must be filed.
Opinion: A written decision of a judge, Stay: A court order that temporarily
setting forth the reasons for the decision suspends court proceedings or the effect of
and the facts and law on which the a judgment.
decision is based.
Summary Judgment Motion: A motion
Plaintiff: The person who files the requesting the court to rely on facts that
complaint in a civil lawsuit. are not in dispute to rule in one party’s
favor without a trial.
Pro Se: A term that refers to an individual
who presents their own case without an Transcript: A written record of everything
attorney. that was said during a court proceeding,
such as a hearing or trial. The transcript is
prepared by a court reporter and filed on
the case docket.

A‐2
 In The United States Court of Federal Claims
Form 2
Cover Sheet
Plaintiff(s) or Petitioner(s)

Names: _______________________________________________________________________

Location of Plaintiff(s)/Petitioner(s) (city/state): _______________________________________

______________________________________________________________________________
(If this is a multi-plaintiff case, pursuant to RCFC 20(a), please use a separate sheet to list additional plaintiffs.)

Name of the attorney of record (See RCFC 83.1(c)): ___________________________________

Firm Name: _______________________________________________________________

Contact information for pro se plaintiff/petitioner or attorney of record:

Post Office Box: ______________________________________________________

Street Address: ______________________________________________________
City-State-ZIP: ______________________________________________________
Telephone Number: ______________________________________________________
E-mail Address: ______________________________________________________

Is the attorney of record admitted to the Court of Federal Claims Bar? Yes No

Nature of Suit Code: __________ Agency Identification Code: ____________

Select only one (three digit) nature-of-suit code from the attached sheet. Number of Claims Involved: ____________

Amount Claimed: $_______________________

Use estimate if specific amount is not pleaded.

Bid Protest Case (required for NOS 138 and 140):

Indicate approximate dollar amount of procurement at issue: $____________________________
Is plaintiff a small business? Yes No
Was this action proceeded by the filing of a Yes No Solicitation No. _____________
protest before the GAO?
If yes, was a decision on the merits rendered? Yes No

Income Tax (Partnership) Case:

Identify partnership or partnership group: _________________________

Takings Case:
Specify Location of Property (city/state): _____________________

Vaccine Case:
Date of Vaccination: ___________________________

Related case:
Is this case directly related to any pending or previously filed Yes No
case(s) in the United States Court of Federal Claims? If yes, you
are required to file a separate notice of directly related case(s). See RCRC 40.2.
A‐3
 Nature-of-Suit Codes for General Jurisdiction Cases
100 Contract – Construction – (CDA) 206 Tax – Excise 348 Military Pay – Reinstatement
102 Contract – Fail to Award – (CDA) 208 Tax – Gift 350 Military Pay – Relocation Expenses
104 Contract – Lease – (CDA) 210 Tax – Income, Corporate 352 Military Pay – Retirement
106 Contract – Maintenance – (CDA) 212 Tax – Income, Individual 354 Military Pay – SBP
108 Contract – Renovation – (CDA) 213 Tax – Income, Individual 356 Military Pay – Other
110 Contract – Repair – (CDA) (Partnership)
112 Contract – Sale – (CDA) 214 Tax – Informer’s Fees 500 Carrier – transportation
114 Contract – Service – (CDA) 216 Tax – Preparer’s Penalty 502 Copyright
116 Contract – Supply – (CDA) 218 Tax – Railroad 504 Native American
118 Contract – Other – (CDA) Retirement/Unemployment Tax Act 506 Oil Spill Clean Up
220 Tax – TEFRA Partnership – 28:1508 507 Taking – Town Bluff Dam
120 Contract – Bailment 222 Tax – Windfall Profit Overpayment 508 Patent
122 Contract – Bid Preparation Costs – Interest 509 Taking – Addicks & Barker
124 Contract – Medicare Act 224 Tax – 100% Penalty – 26:6672 – Reservoirs
125 Contract – Affordable Care Act Withholding 510 Taking – Personalty
126 Contract – Realty Sale 226 Tax – Other 512 Taking – Realty
128 Contract – Subsidy 513 Taking – Rails to Trails
130 Contract – Surety 300 Civilian Pay – Back Pay 514 Taking – Other
132 Contract – Timber Sale 302 Civilian Pay – COLA 515 Unjust Conviction and Imprisonment
134 Contract – Other 303 Civilian Pay – Disability Annuity 516 Miscellaneous – Damages
304 Civilian Pay – FLSA 518 Miscellaneous – Lease
136 Contract – Other – Wunderlich 306 Civilian Pay – Overtime 520 Miscellaneous – Mineral Leasing
Compensation Act
138 Contract – Protest (Pre Award) 308 Civilian pay – Relocation Expenses 522 Miscellaneous – Oyster Growers
140 Contract – Protest (Post Award) 310 Civilian Pay – Suggestion Award Damages
312 Civilian Pay – Other 524 Miscellaneous – Safety Off. Ben.
200 Tax – Allowance of Interest Act
202 Tax – Declaratory Judgment – 340 Military Pay – Back Pay 526 Miscellaneous – Royalty/Penalty
28:1507 342 Military Pay – CHAMPUS Gas Production
204 Tax – Estate 344 Military Pay – Correct records 528 Miscellaneous – Other
346 Military Pay – Correct/Reinstate 535 Informer’s Reward
536 Spent Nuclear Fuel

Nature-of-Suit Codes for Vaccine Cases

449 Injury – Hepatitis A 485 Injury – Hemophilus Influenzae 477 Death – Pertussis
453 Injury – Pneumococcal Conjugate 486 Injury – Varicella 478 Death – Polio – inactive
456 Injury – DPT& Polio 490 Injury – Rotavirus 479 Death – Polio – other
457 Injury – D/T 492 Injury – Thimerosal 480 Death – Rubella
458 Injury – DTP/DPT 494 Injury – Influenza (Flu) 481 Death – Tetanus & Diphtheria
459 Injury - Measles 496 Injury – Meningococcal 482 Death – Tetanus & Tox.
460 Injury – M/M/R 498 Injury – Human Papillomavirus 483 Death – Other
461 Injury – Measles/Rubella 487 Death – Hepatitis B
462 Injury – Mumps 452 Death – Hepatitis A 488 Death – Hemophilus Influenaze
463 Injury – Pertussis 454 Death – Pneumococcal Conjugate 489 Death – Varicella
464 Injury – Polio – inactive 470 Death – DPT & Polio 491 Death – Rotavirus
465 Injury – Polio – other 471 Death – D/T 493 Death – Thimerosal
466 Injury – Rubella 472 Death – DTP/DPT 495 Death – Influenza (Flu)
467 Injury – Tetanus & Diphtheria 473 Death – Measles 497 Death – Meningococcal
468 Injury – Tetanus & Tox. 474 Death – M/M/R 499 Death – Human Papillomavirus
469 Injury – Other 475 Death – Measles/Rubella
484 Injury – Hepatitis B 476 Death – Mumps

A‐4
 AGENCY CODES

AGR Agriculture SBA Small Business Administration

AF Air Force TRN Department of Transportation

ARM Army TRE Department of Treasury

AEC Atomic Energy Commission VA Department of Veterans Affairs

COM Department of Commerce VAR Various Agencies

DOD Department of Defense O Other

DOE Department of Energy

ED Department of Education

EPA Environmental Protection Agency

GPO Government Printing Office

GSA General Services Administration

HHS Health and Human Services

HLS Homeland Security

HUD Housing and Urban Development

DOI Department of the Interior

ICC Interstate Commerce Commission

DOJ Department of Justice

LAB Department of Labor

MC Marine Corps

NAS National Aeronautical Space Agency

NAV Navy

NRC Nuclear Regulatory Commission

PS Postal Service

STA State Department

A‐5
 In the United States Court of Federal Claims
)
__________________________________ )
)
__________________________________ )
Plaintiff(s), )
Case No. ______________________
)
v. )
Judge ______________________
)
THE UNITED STATES, )
)
Defendant. )
)

COMPLAINT
Your complaint must be clearly handwritten or typewritten, and you must sign and declare under
penalty of perjury that the facts are correct. If you need additional space, you may use another blank
page. A fillable pdf is available at http://uscfc.uscourts.gov/filing-a-complaint.
If you intend to proceed without the prepayment of filing fees (in forma pauperis (IFP)), pursuant to 28
U.S.C. § 1915, you must file along with your complaint an application to proceed IFP.
1. JURISDICTION. State the grounds for filing this case in the United States Court of Federal
Claims. The United States Court of Federal Claims has limited jurisdiction (see e.g., 28 U.S.C.
§§ 1491-1509).

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

A‐6
2. PARTIES

Plaintiff, _____________________________, resides at_______________________________________

(Street Address)

_________________________________________________, __________________________________
(City, State, ZIP Code) (Telephone Number)

If more than one plaintiff, provide the same information for each plaintiff below.

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

3. PREVIOUS LAWSUITS. Have you begun other lawsuits in the United States Court of Federal
Claims? Yes No

If yes, please list cases:

4. STATEMENT OF THE CLAIM. State as briefly as possible the facts of your case. Describe
how the United States is involved. You must state exactly what the United States did, or failed
to do, that has caused you to initiate this legal action. Be as specific as possible and use
additional paper as necessary.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

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5. RELIEF. Briefly state exactly what you want the court to do for you.

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
I declare under penalty of perjury that the foregoing is true and correct.

Signed this __________ day of _____________________, ________.

(day) (month) (year)

__________________________________________
Signature of Plaintiff(s)

A‐8
 In the United States Court of Federal Claims
)
__________________________________ )
)
__________________________________ )
Plaintiff(s), )
Case No. _______________________
)
v. )
Judge _______________________
)
THE UNITED STATES, )
)
Defendant. )
)

Application to Proceed In Forma Pauperis

I,____________________________________, declare that the following is true and correct; that I am the
plaintiff in the above entitled case; that in support of my application to proceed without being required to
prepay fees, costs, or give security thereof, I state that because of my poverty, I am unable to pay the costs
of said proceedings or to give security thereof, and that I am entitled to relief pursuant to 28 U.S.C. §
1915.

1. Are you incarcerated? □ Yes □ No (If the answer is no, go to question 2.)

I am being held at: ________________________________________________________________

Do you receive any payment from this institution? □ Yes □ No

Monthly amount: ________________________________________

□ I have attached a certified copy of my trust fund account statement (or institutional equivalent) for
the six (6)-month period immediately preceding the filing of this complaint, as required by 28
U.S.C. § 1915(a)(2).

□ I have attached a “Prisoner Authorization form” authorizing the Facility where I am incarcerated
to deduct the filing fee from my account in installments and to send to the court certified copies
of my account statements for the past six (6) months.

2. Are you currently employed? □ Yes □ No

a. If the answer is yes, give the name and address of your employer and state the amount of your
salary or wages per month (both gross and net).

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 b. If the answer is no, state the date of last employment and the amount of your salary or wages
per month (both gross and net).

3. Within the past twelve (12) months, have you received any money from the following sources?
a. Business, profession, or other form of self-employment? □ Yes □ No
b. Rent payments, interest, or dividends? □ Yes □ No
c. Pensions, annuities, or life insurance payments? □ Yes □ No
d. Gifts or inheritances? □ Yes □ No
e. Any other sources? □ Yes □ No

If the answer to any of the above is yes, describe each source of money and the amount received
in the last twelve (12) months, and what you expect to receive in the future.

If the answer is no to all of the questions above, explain how you are paying your expenses.

4. How much money do you have in cash or in a checking, savings, or inmate account?

5. Do you own any automobiles, real estate, stocks, bonds, securities, trusts, jewelry, art work, or other
financial instruments or items of value, including any items of value held in someone else’s name? If
so, describe each property and its approximate value.

6. Do you have any housing, transportation, utilities, or loan payments, or other regular monthly
expenses? If so, describe and provide the amount of each monthly expense.

7. List any persons dependent upon you for support, your relationship to those persons, and how much
you contribute toward their support.

8. Do you have any debts or financial obligations not described above? If so, describe the amounts
owed and to whom they are payable.

Affidavit: I declare under penalty of perjury that the foregoing is true and correct and that a false
statement may result in dismissal of my complaint.

________________________________________ _______________________________________
(Date) (Signature of Applicant)

________________________________________ _______________________________________
Prison Identification # (if incarcerated) Print Name (Last, First, MI)

A‐10
 In the United States Court of Federal Claims
)
__________________________________ )
)
__________________________________ )
)
Plaintiff, ) Case No. _______________________
)
v. ) Judge _______________________
)
THE UNITED STATES, )
)
Defendant. )
)

Prisoner Authorization

By signing below, I acknowledge that:

1. because I filed this action as a prisoner,9 I am required by statute (28 U.S.C. § 1915(b)(1)) to pay
the full filing fees for this case, even if I am granted the right to proceed in forma pauperis (IFP),
that is, without prepayment of fees;
2. if I am granted IFP status, the $350 filing fee will be deducted from my prison account, even if my
case is dismissed or I voluntarily withdraw it.

I authorize the agency holding me in custody to calculate the amounts specified by 28 U.S.C. § 1915(b),
deduct those amounts from my prison trust fund, and disburse those amounts to the court.
This authorization applies to any agency into whose custody I may be transferred and to any other court to
which my case may be transferred.

_____________________________________ _____________________________________
(Date) (Signature of Applicant)

_____________________________________ _____________________________________
Prison Identification # Print Name (Last, First, MI)

_____________________________________________________________________________________
Address City State ZIP Code

9
A prisoner is “any person incarcerated or detained in any facility who is accused of, convicted of,
sentenced for, or adjudicated delinquent for, violations of criminal law or the terms and conditions
of parole, probation, pretrial release, or diversionary program.” 28 U.S.C. § 1915(h).
A‐11
 In the United States Court of Federal Claims
)
__________________________________ )
)
__________________________________ )
Plaintiff(s), )
Case No. ______________________
)
v. )
Judge ______________________
)
THE UNITED STATES, )
)
Defendant. )
)

CERTIFICATE OF SERVICE
I hereby certify that on , , a copy of
,
was mailed via , to ,
at .

_____________________________________
(Signature of Applicant)

(Printed Name)

(Street Address)

(City, State, ZIP Code)

(Phone Number)

A‐12
 In the United States Court of Federal Claims
)
__________________________________ )
)
__________________________________ )
Plaintiff(s), ) Case No. ______________________
)
v. ) Judge ______________________
)
THE UNITED STATES, )
)
Defendant. )
)

NOTICE OF CHANGE OF ADDRESS

Please take notice that my address and/or contact information has changed. My new
address and contact information are:

_________________________________________
Name

_________________________________________
Address

_________________________________________
City, State, ZIP

_________________________________________
Telephone Number

_________________________________________
E-mail Address

__________________________________
(Signature of Plaintiff)

__________________________________
(Date)

A‐13
 In the United States Court of Federal Claims
)
__________________________________ )
)
__________________________________ )
Plaintiff(s), )
Case No. ______________________
)
v. )
Judge ______________________
)
THE UNITED STATES, )
)
Defendant. )
)

NOTICE OF APPEAL

Notice is hereby given that in the

(list all parties taking the appeal)

above named case hereby appeal to the United States Court of Appeals for the Federal Circuit from

the entered in this action on

(describe document being appealed; e.g. final judgment, order)

.
(filed date of document being appealed)

_____________________________________
(Signature of Appellant of Attorney)

(Printed Name)

(Street Address)

(City, State, ZIP Code)

(Phone Number)

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