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

`I Case1:07-cv—00433-JJF D0cument6 Filed 07/30/2007 Page10f2
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF DELAWARE
SHAKIR TAQI AHMAD, _ )
Plaintiff, g
v. g Civil Action No. 07-433-*** —
CONTRACTED HEALTH SERVICES, g `
AND DOCTOR IONNA, )
Defendants. g i
AUTHORIZATION i
I, Shakir Taqui Ahmad, SBI #535348, request and authorize _
the agency holding me in custody to disburse to the Clerk of the I ,
Court the initial partial filing fee of $9.25 and the subsequent
payments pursuant to 28 U.S.C. § l915(b) and required by the
Court’s order datedijibgg §D§“ , 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 I
. understand that the entire filing fee may be deducted from my ~
1
trust account regardless of the outcome of my civil action. This 1
authorization shall apply to any other agency into whose custody
I may be transferred.
nate; v`\y9~kyo"\ , 2007.
if i l i` ‘/“*i — `Y §, QA N
; TTMMITWE '’‘»‘‘· E Signature of Plaintiff
I I FMI,. Bmw ;; I I
5 .,._
_..i_ _.,,.. I i

Case 1 :07-cv—00433-JJF Documentji _ I ,iz·"»·'.· I I _
= .=:·:·.=;· . 1:2
? {F it s : _
"i'1" ’ .; 1 `
*1 é 2 -
Em
$1 vn *11 2 *1 *‘":··
1 1 2 11 ···£
1 12 U ` _
1 Q 1*
5 > é e ` l W} -I-EE
2,0
{ga
0 `
W _,
1 or K} <> ¤> 1,+2
1 $1 ‘ 7
. Z? __ 1 /1’ v
/ · 4
1 ` V 0/ ./ /9
1 o *:3
g I ' lf;}
1 if 1.;:
a 7 A 4 _ _ ) •r··i
1 _· 1 9 J {Eg};
1 · _‘ J " 1 UO iff:
g V ` D V Il Q l •,·»•,!
1 A 13** .1 of ‘ .
g 1} Z Q a
1 2 g a
2 A ·> / D E1 E]
1 r · — ¤ 2 as `
1 1;;; O
1 ,,0 g g g
1 §..,» { an 0
1— , rm Q H
§ cn Q
3 /1 ·¤ Q —<
7 f 3 1:.. Z 1
1 A FEE :43 ·—·
1 E m W 2 1 —-
Q _· 1--4 > U2 Q »·—< (.0 '