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

Case1:O5-cv—OOO67—SLR D0cument5 Filed O3/21/2005 Page10f1
IN THE UNITED STATES DISTRICT COURT m YE
FOR THE DISTRICT OF DELAWARE Q g F
w , I y
WILLIAM FREDERICK DAVIS, III, g L =k- i
Plaintiff, ) if B W U AS-. _ M LKA
v. g Civ. No. 05-067-SLR
STATE OF DELAWARE, DEPARTMENT OF g
CORRECTION, RAPHAEL WILLIAMS, )
STAN TAYLOR, FIRST CORRECTIONAL )
MEDICAL, and MENTAL HEALTH, )
Defendants. g
AUTHORIZATION
I, William Frederick Davis, III, request and authorize the
agency holding me in custody to disburse to the Clerk of the
Court the initial partial filing fee of $1.36 and the subsequent
payments pursuant to 28 U.S.C. § l9l5(b) and required by the
Court’s order dated [ghlkgfyjg , 2005.
This authorization is furnished in connection with the
filing of a civil action, and I understand that the filing fee
for the complaint is $250.00. 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.
mara; 3 —-/7-vg , 2005.
Wil iam Frederic Davis, III