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

Case 1:05-cv-00624-SLR Document 11 Filed 12/29/2005 Page 1 of 2
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF DELAWARE
/ §’<.-Q fb L2 JPL
HARRY T. COLLINS, )
)
Plaintiff, )
>
v. ) Civ. No. 05-624 SLR
)
LINDA HUNTER AND HRYCT )
MEDICAL DEPARTMENT, ) F
) I L E D
Defendants. )
msc 2 0 2005 * .
AUTHORIZATION
US.D5TWCTCOUHI
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I, Harry T. Collins, request and authorize the agency
holding me in custody to disburse to the Clerk of the Court the
initial partial filing fee of $78.38 and the subsequent payments
pursuant to 28 U.S.C. § l9l5(b) and required by the Court’s order
dated October l2, 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: { gg ¢/ { JS! , 2005.
=>¤ 2. 0 2
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“’ fl Name Plaintiff
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