Free Authorization Form (PLRA) - District Court of Delaware - Delaware

Case 1:07-cv-00365-JJF Document 16 Filed 12/28/2007 Page 1 of 2
IN THE UNITED STATES DISTRICT COURT A
FOR THE DISTRICT OF DELAWARE
I USHANGO OWENS, )
>
Plaintiff, >
)
v. ) Civil Action No. 07-365-JJF
)
GOVERNOR RUTH ANNE MINOR, )
DELAWARE STATE EMPLOYEES, ) ·
OFFICER FOX, OFFICER KIRKLIN, ) !mMwm%TmTwwWwwmTT,h:1,, AT___ _,_...T
MAYOR JAMES BAKER, WILMINGTON 1 ._‘‘‘ " " ’ Q E
HOSPITAL EMERGENCY, ) T, ..,,.. .,,... ,,,._, 5
WILMINGTON POLICE DEPARTMENT, }
GANDER HILL PRISON HRYCI, J I DEC 28 gnu?
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D P a t . y ..,.., ,....
i_,.L.,.l..,I1 E . ..., I ..,_ ._,.,_,.,,
I, Ushango Owens. SBI #240623, request and authorize the
agency holding me in custody to disburse to the Clerk of the
Court the initial partial filing fee of $2.64 and the subsequent
payments pursuant to 28 U.S.C. § l9l5(b) and required by the
Court’s order dated 2007.
This authorization is furnished to the Clerk of Court in
connection with the filing of a civil action, and I understand
that the filing fee for the complaint is $350.00. I also
understand that the entire filing fee may be deducted from my
trust account regardless of the outcome of my civil action. This
authorization shall apply to any other agency into whose custody
I may be transferred.
Date; |?;*·=ig;h»,¤& Z, , 2007. ·~q':·° y _ _
A /1 A ,{? A? = 1 |·‘¢°G7I··? $,.1*-1-¤Y5
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Signaturgnéf Plaintiff . _ _
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Case 1:07-cv-00365-JJF Document 16 Filed 12/28/2007 Page 2 0f 2
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