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If the answer is yes, state the total value of the items owned. 4. 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. A party may file a motion to proceed on appeal in forma pauperis in the court of appeals within 30 days after service of the notice prescribed in Rule 24(a)(4). My affidavit or sworn statement is attached. I believe I am entitled to relief. Complete the case caption as you did on the motion for leave to proceed in forma pauperis. You will need one copy of the civil complaint with original signature for the magisterial district judge. Motion must contain:.