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

= Case 1:07-cv-00059-SLR Document 7 Filed O3/O9/2007 Page1 of2
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT or DELAWARE {
MYLES A. HART, )
Plaintiff, g
v. g Civ- No- 07·59·SLRl.. ...,. .r,.lTI;&Irl--_ ... , ,,,.
CORRECTIONAL MEDICAL sERvIcE, g Z ·,.. .r§ l&;§:®lLi
AUTHORIZATION ___.
BD Srcrmrwcf
I, Myles A. Hart, SBI #00499250 , request and authorize the
agency holding me in custody to disburse to the Clerk of the
Court the initial partial filing fee of $2é.23 and the subsequent
payments pursuant to 28 U.S.C. § l9l5{b) and required by the _
Court’s order dated thgfgjj | , 2007.
.0 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 transferred.
Date: i O [ , 2007.

Case 1:07-cv-00059-SLR Document 7 Filed O3/O9/2007 Page 2 of 2
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