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

__ 5 Case 1:07-cv-00504-SLR D0cument6 Filed O9/O4/2007 Page1 0f2
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF DELAWARE
ADAM WENZKE, )
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Plaintiff, ) _
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v. ) Civil Action No. 07-504-***
)
CORRECTIONAL MEDICAL SYSTEMS, )
FIRST CORRECTIONAL MEDICAL, )
NURSE MAGGIE, DR. TATAGARI, )
DR. HAQUE, NURSE DIANNE, ) {wx
DR. TADEO, DR. DOROSIER, ) gm”"“"”_d**-*_'”d—d*d%
MR. ALTON, DR. SMITH, MR. JIM ) E @ E H W
WELCH, BETTY BRADLEY, NECHELLE ) F“dM#**_¤d****Etl§
D. BUTCHER, STEPHANIE MAWBRAY, ) _ F , ogy fhjw
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AND DR. JOHN DOE, ) N
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Defendants. WQHETQFDHAWME
AUTHORIZATION
· I, Adam Wenzke, SBI #182595, request and authorize the
agency holding me in custody to disburse to the Clerk of the
Court the initial partial filing fee of $22.96 and the subsequent
payments pursuant to 28 U.S.C. § I9l5(b) and required by the
Court’s order dated " , 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

Case1:O7-cv-00504-SLR D6CUr}i€HY€ `"“`' "IE HEd 09/04/2007 Page20f2
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Case 1:07-cv-00504-SLR

Document 6

Filed 09/04/2007

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Case 1:07-cv-00504-SLR

Document 6

Filed 09/04/2007

Page 2 of 2