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

r Case 1:07-cv—00514-SLR Document 21 Filed 09/19/2007 Page 1 of 2
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF DELAWARE g
DAVID R. RUSH, )
I
Plaintiff, )
I _, .¢
v. )Civ. No. 07-514-SLR Eéa
I · ···=
CORRECTIONAL MEDICAL SERVICES,) To ‘iI€l.e*».,
INC., SCOT ALTMAN, CHRISTINE_ -)_ {E,
MALANEY, DONNA PLANTE, ) _. Y _¤
NID JOHN DOE, GAIL ELLER, g. _). x 222
FREDERICK DURST, MD MUHAMMAD) 92
NIAZ, FIRST CORRECTIONAL ) · 5
MEDICAL INC., MD S|`|“I“A ALIE, )
MD MCDONALD, and DEBBIE )
RODWELLER, )
)
Defendants. )
AUT HORIZATION
l,David R. Rush, SBI #173418, request and authorize the agency holding me in
custody to disburse to the Clerk of the Court the
subsequent payments pursuant to 28 U.S.C. § 1915(b) and required by the Courts
order dated 2007.
This authorization is furnished to the Clerk of Court in connection with the filing
ofa 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. n
Date: J/is of /Q , 2007.
I Signature of Plaintiff

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Case 1:07-cv-00514-SLR

Document 21

Filed 09/19/2007

Page 1 of 2

Case 1:07-cv-00514-SLR

Document 21

Filed 09/19/2007

Page 2 of 2