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

K; i07—cv-0021 0-SLR Document 5 Filed 05/15/2007 Page 1 of 2
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IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF DELAWARE C C C I
CURTIS L.-EVANS, C f ) f `
Plaintiff, 3
v. g Civ. No. 07-210-SLR I I
THOMAS CARROLL, g , N
Defendants. g
AUTHORIZATION
I, Curtis L. Evans, SBI #340708, request and authorize the agency holding me in i
custody to disburse to the Clerk of the Court the initial partial filing fee of $33.68 and the
subsequent payments pursuant to 28·U.·S.C. § 1915(b) and required by the Court's
order dated [!]g;(' I fl ,2007. I
I
This authorization is furnished to the Clerk of Court in connection with the tiling
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 actio_n. This authorization shall apply to any other agency
into whose custody I may be transferred. -
Date:_ {35,2 ifi , 2007.
g __ ,_... . . ...g Signature of Plaintiff
. = I ,, .. .
A MAY iszririr J
Di l ........ 3 y

Case 1:07-cv-00210-SLR Document 5 Filed 05/15/2007 Page 2 of 2
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