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

Case1:O5—cv—OOO33-GMS D0cument5 Filed O3/O1/2005 Page10f2
IN THE UNITED STATES DISTRICT COURT ii
FOR THE DISTRICT OF DELAWARE
JAMAH K. GROSVENOR, )
> ,
Plaintiff, )
) .
v. ) Civ. N0. O5—O33—§%{
y @#6
THOMAS CARROLL, JOSEPH )
BALLINGER, ELIZABETH BURRIS, )
JIM SIMMS, JOHN DOE — M.D.T., )
JANE DOE - M.D.T., EVELYN )
STEVENSON, Institution Base, )
CLASSIFICATION COMMITTEE )
(IBCC),) JOHN DOE, IBCC, JANE )
DOE, and DEPARTMENT OF )
CORRECTION, )
)
)
Defendants. )
AUTHORIZATION
I, Jamah K. Grosvenor, request and authorize the agency
holding me in custody to disburse to the Clerk of the Court the
initial partial filing fee of $ll.ll and the subsequent payments
pursuant to 28 U.S.C. § l9l5(b) and required by the Court’s order
dated JJ. 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 $l50.00. 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

Case 1:05-cv-00033-GIVIS Document5 Filed O3/O1/2005 Page2of2
to a r agency into whose custody I may be transferred.
D8t€€*0 ` c f I 2005-
juan K. ro eno
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