FEDERAL RULES OF APPELLATE PROCEDURE 

                   Fifth Circuit Local Rules, Effective December 1, 1994
                 
APPENDIX OF FORMS

Form

  1.	Notice of Appeal to a Court of Appeals From a Judgment or Order of a District Court.
  2.	Notice of Appeal to a Court of Appeals From a Decision of the United States Tax Court.
  3.	Petition for Review of Order of an Agency, Board, Commission or Officer.
  4.	Affidavit to Accompany Motion for Leave to Appeal In Forma Pauperis.
  5.	Notice of Appeal to a Court of Appeals From a Judgment or Order of a District Court or a Bankruptcy Appellate Panel.

APPENDIX OF FORMS

FORM 1.   NOTICE OF APPEAL TO A COURT OF APPEALS 
FROM A JUDGMENT OR ORDER OF A DISTRICT COURT

United States District Court for the 
           District of             

										File Number                    

			A.B., Plaintiff			}
								}
				v.				}	
								}  Notice of Appeal
								}
			C.D., Defendant		}

	Notice is hereby given that        (here name all parties taking the appeal)    ,  (plaintiffs) (defendants) in the above named case,* hereby appeal to the United States Court of Appeals for the                Circuit (from the final judgment)  (from an order (describing it)) entered in this action on the        day of              , 19    .

									(s)                                                 	  			   

									Attorney for                                         				   

									Address:                                          

*  See Rule 3(c) for permissible ways of identifying appellants.  

FORM 2.   NOTICE OF APPEAL TO A COURT OF APPEALS 
   FROM A DECISION OF THE UNITED STATES TAX COURT       

UNITED STATES TAX COURT
Washington, D.C. 

		A.B., Petitioner			}
								}
			v.					}  Docket No.                           
								}
		Commissioner of Internal		}
		Revenue, Respondent		}

Notice of Appeal

	Notice is hereby given that    (here name all parties taking the appeal) *    hereby appeal to the United States Court of Appeals for the              Circuit from  (that part of) the decision of this court entered in the above captioned proceeding on the           day of                            , 19     (relating to                     ). 

									(s)                                                    			    

									Counsel for                                         			

    									Address:                                            	

					   
*  See Rule 3(c) for permissible ways of identifying appellants.			

FORM 3.   PETITION FOR REVIEW OF ORDER OF AN AGENCY, 
BOARD, COMMISSION OR OFFICER 

United States Court of Appeals
for the                   Circuit

		A.B., Petitioner			}
								}
			v.					}  Petition for Review
		XYZ Commission,			}		
		Respondent				}

 
	    (here name all parties bringing the petition)*    hereby petition the court for review of the Order of the XYZ Commission (describe the order) entered on                     , 19    . 

									(s)                                           
									    Attorney for Petitioners 			 
									    Address:                                    

*  See Rule 15.         

FORM 4.   AFFIDAVIT TO ACCOMPANY MOTION FOR 
LEAVE TO APPEAL IN FORMA PAUPERIS 

United States District Court for the
           District of            

		United States of America		}
								}
				 v.			   	}  No.                              
								}
				A.B.				}	 	

Affidavit in Support of Motion to Proceed
on Appeal in Forma Pauperis

	I,                     being first duly sworn, depose and say that I am the                     , in the above-entitled case;  that in support of my motion to proceed on appeal without being required to prepay fees, costs or give security therefor, I state that because of my poverty I am unable to pay the costs of said proceeding or to give security therefor;  that I believe I am entitled to redress;  and that the issues which I desire to present on appeal are the following:

	I further swear that the responses which I have made to the questions and instructions below relating to my ability to pay the cost of prosecuting the appeal are true. 

	1.  Are you presently employed?

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

	b.  If the answer is no, state the date of your last employment and the amount of the salary and wages per month which you received.

	2.  Have you received within the past twelve months any income from a business, profession or other form of self-employment or in the form of rent payments, interest, dividends, or other source?

	a.  If the answer is yes, describe each source of income, and state the amount received from each during the past twelve months.

	3.  Do you own any cash or checking or savings account?

	a.  If the answer is yes, state the total value of the items owned.

	4.  Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings and clothing)?

	a.  If the answer is yes, describe the property and state its approximate value.

	5.  List the persons who are dependent upon you for support and state your relationship to those persons.

	I understand that a false statement or answer to any questions in this affidavit will subject me to 
penalties for perjury.

SUBSCRIBED AND SWORN TO before me this                  day of                         , 19    .

	Let the applicant proceed without prepayment of costs or fees or the necessity of giving security therefor. 

									              District Judge 

FORM 5.   NOTICE OF APPEAL TO A COURT OF APPEALS
FROM A JUDGMENT OR ORDER OF A DISTRICT COURT
OR A BANKRUPTCY APPELLATE PANEL 

United States District Court for the
             District of            

	In re						}
		                                    ,	}
            		        Debtor			}
						   		}
		                                    ,	}
          		       Plaintiff			}    File No.                  
                      					}
           		           v.			}
		   						}		
		                                    ,	}
           		       Defendant		}

Notice of Appeal to
United States Court of Appeals
for the               Circuit

	                            , the plaintiff [or defendant or other party] appeals to the United States Court of Appeals for the                     Circuit from the final judgment [or order or decree] of the district court for the district of                     [or bankruptcy appellate panel of the                     circuit], entered in this case on                      , 19     [here describe the judgment, order, or decree]                          .  	

	The parties to the judgment [or order or decree] appealed from and the names and addresses of their respective attorneys are as follows:

								Dated                                           

								Signed                                          
						 	   		        Attorney for Appellant

								Address: