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

Case 1:07-cv-00125-JJF Document 5 Filed O3/22/2007 Page1 of 2
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF DELAWARE
RAYMOND E. BLAKE, )
Plaintiff, g
v. ; Civil Action No. 07-125 JJF
RUTH ANN MINNER, 5 ME
CARL C. DANBERG, ) @§_
JAMES M. BAKER, and ) §3_i
DAVID PRADO, > *’ g . p
Defendants. 3 lg
AUTHORIZATION Q ;
I, Raymond E. Blake, SBI #377092, request and authorize the?%
agency holding me in custody to disburse to the Clerk of the
Court the initial partial filing fee of $16.14 and the subsequent
payments pursuant to 28 U.S.C. § 1915(b) and required by the
Court’s order dated. “A¢}££lf SY` , 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 _.,_ ·
Date: , 2007.
”‘‘` _ _ ___ r, _, ....__ z z · ‘
Signature of Plaintiff


Case 1 :07-cv-OO125;J_JF n |§)0cum nt 5 Filed O3/22/2007 Page 2 bf 2
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