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

Case 1:07-cv—00269-SLR g Document 5 Filed 06/06/2007 Page 1 of 2
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF DELAWARE
A KENNETH M. SMITH, ) g
Plaintiff, l
v. l Civ. No. 07—269 SLR B
STAN TAYLOR, THOMAS CARROLL, l
FIRST CORRECTIONAL MEDICAL )
INC., DAVID VVILKERSON, and GAIL )
ELLER, )
Defendants. l
AUTHORIZATION _
I, Kenneth M. Smith, SBI #193906, request and authorize the agency holding me
_ in custody to disburse to the Clerk of the Court the Initial partial filing fee of $23.51 and n ’
the subsequent payments pursuant to 28 U.S.C. § 1915(b) and required by the Court’s
l order dated lllncg gg , 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 tiling 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: .5*- .é’·=i>`——c> ‘>=· , 2007.
· - , i3i1‘1"1 .
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Case 1 :07-cv—00269-SLR Document 5 Filed 06/06/2007 Page 2 of 2
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