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

Case1:07-cv—00O06—G|\/IS D0cument5 Filed 01/25/2007 Page10f2
l IN THE UNITED STATES DISTRICT CCURTT y _. Q E
_ _ __ FOR THE DISTRICT OF DELAWARE C l ___ q
KEVIN C. BRATHWAITE ) ` l 2
Plaintiff, ; y
v. l _ g; Civil Action No. 07-6 GMS -
CORRECTIONAL MEDICAL SERVICES, g \
_ scoTT S. ALTMAN, ) ...ill. _ _,,,. .::.. .,.ll. I
, t tt tttt C({ I
Defendanw ..,¤/vn
AUTHORIZATION ii iT3iT,r rr? rh ._.. .._.. Qf é
I, Kevin C. Brathwaite, SBI #3l5294 , re \
the agency holding me in custody to disburse to the Clerk of the <
Court the initial partial filing fee of $39.47 and the subsequent
payments pursuant to 28 U.S.C. § l9l5(b) and required by the
Court's order [$?>, 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 thefcomplaint is $350.00. I also l
understand that the entire filing fee may be deducted from my i
trust account regardless of the outcome of my civil action. This i
authorization shall apply to any other agency into whose custody y
I may be transferred. i
Date: J/‘l&0FH`y, 23 , 2007. E i
Q %· ·‘‘‘ 7. ......
/,./ A yyy___ _M_;_______,T,_;;;...
Signat e of Plaintiff
l

Case1:07-cv—00O06—G|\/IS D0cument5 Filed 01/25/2007 Page20f2
U2
E E E §
Q 5 {jd
2
5* ag E x (D ~
E g E M1 S ,
E E § QJ Z
E 0 Q *0
E 5 C} ` I
=¤ 2 Z1 11
I} @2 ** E
g "1 1
2 0 0 10
Q Wk 1
W .
§ 1
E1 Og 2 - , N
__ { ·· X 1
*4 cv 2 <°
\Q r····. r <
KO · 1
€ 1
N 1
. O) » 1
2 X O 1
$11 1
_
xg; U 12 */1 \1_ 1
QQ C?} `* b\ {
Q . 1
'\ 1x V (D 1
‘ ° Zi 1
111 Q ·1 O 1
(\· \ :;¤:·==;r=4»M --r- V .... I
(Al O` O ’ Vb 1
¤ .\\ »—, 1
. **%¤··::%¤—‘§’1qr~¤“·~s;¤;m W
\l >< ‘ T
·
Q {$7*:: E? i
..__ Q 0 1
h··.·»¤1z.... .,u·.1%J`1J'....~ \
, QQ ($1 `?f?Zf%. 1
1 - m — 5;
4f;0_» -1 —$ $3 $0 ‘
-2 ii: ·‘:-·2 G5 1f?'@11{1 G? 1
$:3;;: 11!i1·t11 1
1
CD c> gx W §.,,
1 ;:; '
1