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

Case 1:05-ov-00844—G|\/IS Document 4 Filed 01/17/2006 Page 1 of 1
IN THE UNITED STATES DISTRICT COURT 1
FOR THE QISTRICT OF DELAWARE =
ataon eorre, > I 1
Plaintiff, hg ' I Q
y. 5 Civil Action Not 05—844~GMS I
CHRIS SENATG, MELVEN HENNESY, g g
MICHAEL DELOY, and RICHARD ) ;
Kaaanar, > ·

Defendants. S 1
AUTHORIZnTION 3
I, Eldon Potts, SBI #211193, request and authorize the 3
U agency holding me in custody to dieturee to the Clerk of the
Court the full filing fee of [email protected] pursuant to 28 U.S.C. § \
l9l5(b) and required by the Court’e order dated ` l Q
2¤>¤5*
This authorization ie furniehed in connection with the L
filing of a civil action, and I understand that the filing fee E
for the complaint ie $2S0.00i§ Ijaleo understand that the entire
filing fee may be deducted from my trust account regardless of Q 1
the outcome of my civil action. Thie authorization shall apply lg |
to any other agency into whose custody I may be transferred. g
Da*~2e= 4 §§Cg;7’?7/ gig"? , zoos.
, {QQ,/KQZZ fi { 1
Signature of Plaintiff E 3