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

Case 1:07-cv—OO189-JJF Document 5 Filed 07/O2/2007 Page 1 of 2
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF DELAWARE
Joss A. coLoN, )
)
Plaintiff, )
)
v. ) Civil Action No. 07—l89—JJF i
)
CORRECTIONAL MEDICAL SERVICE, )
H.R.Y.C.I., JOHN OR JANE DOE ) I
Mental Health Department _ ) f--eeee?:F? .,o, ,,,.,,. E?E:-lanmr ,,..-
(H·R·Y·O-I-)» and JOHN OR JANE ) K ..,.. .... :,- - W
DOE Medical Supervisor ) 5 F”m“"0"U `i`O Mllmmw O`O' §
' . , U M
(H.R.Y.C.I.), g n
i F ii E
Defendants. ) % yigggggggfw _____; ggj §
p }§e5i`§ .; ;:, ·
l :-*·if}Q ;Y:`f; :;: ii
AUTQQRIZATIQN i0~eE@r;wnnsaaQe;rn$Hn ,=..
I, Jose A. Colon, SBI #277657, request and authorize the
agency holding me in custody to disburse to the Clerk of the
Court the initial partial filing fee of $6.82 and the subsequent
payments pursuant to 28 U.S.C. § l9l5(b) and required by the
/ .
Court's order dated ChLNL ign , 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 i
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. y
D<51‘C€= 2007-
Ld.2, A —
Si ture of Plaintiff Y
l
E

Case 1 :07-cv—OO189-JJF D0cumer]@§___W__If[led 07/O2/2007 Page 2 of 2
2 A :21 22
.
‘ -»2;.;2:2?2 EEE? $3;

2 QQ iii
2 2
5 if 222 @31 2
2 F; Ei; if "`E
g 22322 2::2 2,.,;
2 *22.,. we ::*.2 , :2
g ·i‘‘‘ mgxj 1223 ‘ m
E "‘iii.£;*;··._${`%2 2432 2;; IEE? .

2 2i¥2L222·f2?2·,2iz2%i222*222’;§i2*222; -—:
; ;;;§i;_2 ii tj} ,.*Z.*?’fs 7'°""
Q :2;%*2252%:2**52*2 ;l»222§§¥¥i§E%E;‘s;$£f
2 E%2€?E;2ri§?;i;·Ei2§§gf;;222;§22;2J§’2 11
2 :i¥&;f§§C:.i22=”i: {QZ E;*C€{E.;j_ Wi; " "":::
*9
2 §~
2 J-
2 y " WE
Q '*••••
2 ,,2 —x» 3
in g __ ...4 ,___£
2 5 ~+ O gg
2 3 3 \ °°
2 -.2
X} 2 $ 9 ···· 2
2 2 \» O ··
i •» r
· 0
I L-
2 O f 2* ,3
u) [3 N 2
‘ * Q ‘ uu
2 » . . 2 .9 .,,4,
xn · 2 *22
2 j. 2 2·.=
2 , T? ..;..
2 :5 TT 3 -··· 2
§ 0,, {Z3
‘ ‘ 22212
2 Eff':
J A ·:-·-{
3 $ 222.
{ E
; E···
2 ’ Z
2 OS2 W
2 ¤>·
2 Eg E §
· D ` ""
{ » 0 Q H
2 g·~·. kl {1 §
E F15 O B
, xo 2 g M :5
2 r- 2 . U ca
¤» g Q c2
i N <¤ gi: <:`
2 #2: 2-4
2 5 EE Fil 2