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☐ Leave is denied to proceed in forma pauperis. Leave is granted to proceed in forma pauperis without payment of the filing fee.(28 U.S.C. § 1746; 18 U.S.C. § 1621.) Signed: Instructions. Complete all questions in this application and then sign it. File the notarized Affidavit of Service with the Clerk of Court. Complete the forms in Section 1 of this packet -- Family Court Coversheet, Summons,. 40-2; and (b) the trial court's order denying or revoking my motion to proceed in forma pauperis. Respectfully submitted,. Signature. Date. The motion must include a copy of the affidavit filed in the district court and the district court's statement of reasons for its action. The Petition to Proceed In Forma Pauperis is to be completed if you feel you cannot afford the filing fees associated with your case.