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

Case 1:06-cv-00778—G|\/IS Document 7 Filed 01/08/2007 Page 1 of 3
U IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF DELAWARE
JTMMIE LEWIS, )
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Plaintiff, ` ) i
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v. ) Civil Action No. 06-778 GMS i
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THOMAS L. CARROLL, ) 5
MAJOR DAVID K. HOLMAN, ) E
D. PIERCE, > E
DR. CANNOLLY, ) {
DR. EOLANDA, D ) Q
DR. ROGERS, ) Q
DR. DURsT, ) . i
LT. LARRY SAVAGE, ) ` V
LT. RALPH HEVERIN, ) Q
SGT. GWENDOLYN EVERETTE, ) j
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MARY SNIDER, `<$""` ) “ 9U(‘1q€bU é
CHARLES BENTON, ) _ _ ‘ A
c/o ROSALIE-VARGAS, ) ~ ‘ V
IMAD JARWAN, ) _{,.. __._ .;.Lwm$,;;a»:a; ...... ,_... —-.- ---- ]
C/O_BUCKLE,- ) ` ` " ` ·‘*‘ ,`?"I _ _ W I 3
OLUFEMI ADESEMOLU, ) i‘" ` "M wm `Y g
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Defendants . ) .i_ ,1 JAN in B
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I, Jimmie Lewis, SBI #506622 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. § l9l5(b) and required
by the Court' s order date [g£49 % , 200-%
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

Case 1:06-cv-00778—G|\/IS Document 7 Filed 01/08/2007 Page 2 of 3
trust account regardless of the outcome of my civil action. This
authorization shall apply to any other agency into whose custody y
I may be transferred. i
Date: , 200% I
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S gnature of Plaintiff
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Case 1:06-cv-00778—G|\/IS Document 7 Filed 01/08/2007 .7Page 3 of 3.
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