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

Case 1:07-cv—OOO25-JJF Document 6 Filed O2/14/2007 Page 1 of 3
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF DELAWARE
DONALD F. BASS, )
)
Plaintiff, )
)
v. ) Civil Action No. 07-25 JJF
)
THOMAS CARROLL, PIERCER, ) -
BETTY BURRIS, SECURITY CHIEF )
DAVID HOLMAN, CAPT. BURTON, } _
LT. RIDER, LT. WELCOME, ) l
` LT. PROFACI, IGC CPL. LISE )
MERSON, SGT. CARTER, )
SGT. GLICK, C/O DEBBIE SCOTT, )
C/O JORDAN, C/O GAVIN, C/O ) i*· ‘,, ‘
PASSLEY, C/O WHITE, and C/O ) _____ _ ___ _ _ ____ _ _ -
CANON, )
A > i ? 1amm 5 i
Defendants. ) E f FEE J Q Q ‘
AUTHORIZATION a. .... ._.. Un_llU1i.W. .sMu
. ED S€?O.I`lV`\9 (V C
I, Donald F. Bass, SBI #187042, request and authorize the
agency holding me in custody to disburse to the Clerk of the
Court the initial partial filing fee of $2.17 and the subsequent
payments-pursuant to 28 U.S.C. § l9l5(b) and required by the
Court's order dated, ¥TiWU&V% 7 , 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
I
authorization shall apply to any other agency into whose custody Y

Case 1:07-cv—OOO25-JJF D0cument6 Filed O2/14/2007 Page20f3
I may be transferred.
Date; QVM" @7 , 2007.
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