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

Case 1:07-cv-00558-SLR Document 6 Filed 11/14/2007 Page 1 of 2
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF DELAWARE
JOSEPH SELBY, I
Plaintiff, g
v. ICN. No. 07-558-SLR
C.I\/IS. and JII\/I WELCH, I
I
I
Defendants. ) V
AUTHORIZATION
I, Joseph Selby, SBI #159971, request and authorize the agency holding mein
custody to disburse to the Clerk of the Court the initial partial filing fee of $11.17 and the
subsequent payments pursuant to 28 U.S.C. § 1915(b) and required by the Court's
order dated &gQ Y} ,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 authorization shall apply to any other agency
into whose custody I may be transferred.
Date; ki ·T,I//"‘;."’ ,2007.
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Case 1:07-cv-00558-SLR

Document 6

Filed 11/14/2007

Page 1 of 2

Case 1:07-cv-00558-SLR

Document 6

Filed 11/14/2007

Page 2 of 2