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

Case 1:05-cv-00052-G|\/IS Document 10 Filed 04/26/2005 Page 1 of 3
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IN THE UNITED STATES DISTRICT COU•T w:;I;“a J; . a.. * E
FOR THE DISTRICT OF DELAWARE f T §§E EE QQE F i
JIMMIE LEWIS, ) Q §T?,%w§E$h___U§ {
Plaintiff, ) — — ._
)
v. ) Civ. No. 05-052-GMS I
)
FIRST CORRECTIONAL MEDICAL )
AND STAFF, GEORGIA SUTTON, )
STANLEY TAYLOR AND STAFF, )
and RAPHAEL WILLIAMS AND )
STAFF, )
)
Defendants. )
AUTHORIZATION
I, Jimmie Lewis, request and authorize the agency holding me
in custody to disburse to the Clerk of the Court the initial
partial filing fee of $6.00 and the subsequent payments pursuant
to 28 U.S.C. § l9I5(b) and required by the Court’s order dated
r
, , 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 $250.00. I also understand that the entire
filing fee may be deducted from my trust account regardless of
the outcome of my civil action. This authorization shall apply
to any other agency into whose custody I may be transferred.
Date: *7/· Q§t~# §%§i , 2005.
“¥mW?$£Qg@E;` £ge§ j$wsi§
Lewis

Case 1:05-cv-00052-G|\/IS Document 10 Filed 04/26/2005 Page 2 of 3
IN THE UNITED STATES DISTRICT COURQ J, _ _ y I
.- 1
FOR THE DISTRICT OF DELAWARE ¥ Q ._ Q ,, e~w Q
JIMMIE LEWIS, } E Q __HN __ ( N L {
Plaintiff, g ; I
v. ) Civ. No. 05-013-GMS
)
RAPHEL WILLIAMS, STANLEY J
TAYLOR AND STAFF, and FIRST )
CORRECTIONAL MEDICAL AND )
STAFF, )
}
)
Defendants. )
AUTHORIZATION
I, Jimmie Lewis, request and authorize the agency holding me
in custody to disburse to the Clerk of the Court the initial
partial filing fee of $6.00 and the subsequent payments pursuant
to 28 U.S.C. § l9l5(b) and required by the Court's order dated
f [ 67 , 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.
rl ·- ___,.
Date: H ______ _ / 9/ , 2005.
I * ‘· `··¤. .;,··
Ji Wg- . ,,,4l ....

Case 1:05-cv-00052-G|\/IS Dbcument 10 Filed 04/26/2005 Page 3 of 3
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