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

Case1:O5—cv-00630-KAJ Document9 FIIed10/28/2005 Page1of1
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF DELAWARE
FAMOUS B. RHOADES, I
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Plaintiff, I
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v, ) Civil Action No. 05-630 JJF
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CORRECTIONAL OFFICER CARLTON )
ADAMS, CORPORAL W. CAMPBELL, ) r__ 4 _
JOSEPH EELANGER - SHIFT ) I _ `.""***
COMMANDER, AND LIEUTENANT ) A' E ETii“£‘[>._ J
LARRY SAVAGE — DISCIPLINARY ) {
HEARING OFFICER, ) 1 .‘“. ~ Alw_ ·
, §§ IL _
Defendants. I
U.S. DISTRIQI.
DISTRICT 0F
AUTHORIZATION E{jI§gOIWn&‘,
I, Famous B. Rhoades, request and authorize the agency
holding me in custody to disburse to the Clerk of the Court the
initial partial filing fee of $3.33 and the subsequent payments
pursuant to 28 U.5.C. § l915(b) and required hy the Court’s order -
dated Qctubgr 2] , 2005.
This authorization is furnished in connection with the U
filing of a civil action, and I understand that the filing fee I
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for the complaint is $250.00. I also understand that the entire I
filing fee may be deducted from my trust account regardless of I
the outcome of my civil action. This authorization shall apply -
to any other agency into whose custody I may be transferred.
Date: , 2005. A
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J · Q at I
Name oh Plaintiff

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