______________No. ______

   vs.

THE UNITED STATES

Judgment with costs having been entered in the above-entitled action on the ___ day of ______, 199_, against ______, the clerk is requested to tax the following as costs:

Fees of the clerk.....................................     $____________
Fees of the reporter for all or any part of the trial       ____________
 or hearing transcript necessarily obtained for use in
 the case.............................................
Fees for witnesses; for statutory fees, see 28 U.S.C.       ____________
 Sec. 1821 (attach itemized listing)..................
Costs for certification or duplication of papers            ____________
 necessarily obtained for use in case, provide number
 of copies, total pages and cost per page*............
Costs incident to taking of depositions (if not of          ____________
 record, then attach statement as to need)............
Costs pursuant to FRAP 39(e)..........................      ____________
Other costs (itemize on attachment)...................      ____________
                Total.................................     $____________
 

 *Allowable duplication costs are restricted to briefs on dispositive matters for a total of 5 copies; additional copies allowable where third parties are present.

State/District of ________,  ss.

County of ____________,

I certify under penalty of perjury that the foregoing costs are correct and were necessarily incurred in this action and that the services for which fees have been charged were actually and necessarily performed and that a copy hereof was this day mailed to ______________ with postage fully prepaid thereon. Executed on ______
  (Date)   
(28 U.S.C. § 1746)

___________________
(Signature of Attorney of Record)

___________________

___________________
(Address)

(As amended Dec. 4, 1992.)