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

_~ Case 1:07-cv-00070-SLR Document 8 Filed O3/26/2007 Paget of2
l IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF DELAWARE
PATRICIA A. SIMPSON, ) A
Plaintiff, g
v. — g Civ. No. 07-70-SLR
VVARDEN RYAN, g
COMMISSIONER STANLEY TAYLOR, )
and BAYLOR MEDICAL STAFF, ) .
Defendants.
AUTHORIZATION
I, Patricia A. Simpson, SBI #307575, request and authorize the agency holding
me in custody to! disburse to the Clerk of the Court all payments pursuant to 28 U.S.C.
§ 1915(b) and required by the Court’s order dated m&rCJ~.. [ Q , 2007.
This authorization is furnished to the Clerk of Court in connection with the tiling
of a civil action, and I understand that the tiling 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.
Dateipw 4. .1 ,2007. _
~==- nature of Plaintiff -·' .
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Case SLR Document 8 Filed O3/26/2007 Page 2 of 2
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