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

Case 1:07-cv-00448-GIVIS Document 11 Filed 09/04/2007 Page 1 012
I I I
IN TEE UNITED STATES DISTRICT COURT j
FOR THE DISTRICT op DELAWARE l ~·
Ler.,AJ l
RUSSELL STEEDLEY, g l
Plaintiff, ) U l
. V. l Civil Action No. 07-448-*** Q
- CORRECTIONAL MEDICAL SERVICES{ g . .
UNKNOWN EMPLOYEES, AND )
CORRECTIONAL MEDICAL SERVICES ) Q?
REGION, - ) _ _ ‘
Defendants. _ ’ l »
- AUTHORIZATION ;
l T,Russell Steedley, SBI #249572 , request and authorize the
agency holding me in custody to disburse to the Clerh of the I
I Court the initial partial filing fee of $12.63 and the subsequent f
payments pursuant to 28 U.S.C. § l9l5(b} and required by the _
Court’s order dated Gale ir , 2007. 9
This authorization is furnished to the Clerk of Court in T
connection with the filing of a civil action} and I understand I
that the filing fee for the complaint is $350.00. I also _i_
Y understand that the entire filing fee may be deducted from my l
trust account regardless of the outcome of my civil action. This E
authorization shall apply to any other agency into whose custody -
I [Tidy DE'. l1I'8.I1Sf€I`]C&Cl. I l l
Date$`»4AjI=Z$-. . , 2007. __-__ -_; __ _ -_-y I Q
dn U an U Il adb 2 l Signature of Plaintiff Mm l:

Case 1:07-cv-00448-GIVIS Document 11 Filed O9/O4/2007 Page 2 0f 2
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