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

Case 1:05-cv-00306-JJF Document 7 Filed 07/27/2005 Page1 of 2
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT or DELAWARE
IVAN L. MENDEZ, I
J
Plaintlrr, I
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v. I Civ. No. 05-306-JJF wN_ n_ ,
3 I It II S ='7 —_l
DELAWARE PSYCHIATRIC CENTER, ) ,ax;j;·_a3_$
Defendant. I .-; _,~ _,w§ M
AuTH0R1zAT101~: ----= `.
I, Ivan L. Mendez, SBI #453351, request and authorize the
agency holding me in custody to disburse to the Clerk of the
Court all payments pursuant to 28 U.S.C. § l9l5(b} and required
by the Court's order dated O @§E@§ J, 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 3
the outcome of my civil action. This authorization shall apply KI
' I
to any other agency into whose custody I may be transferred. Q U
Date: __Q) {25 [os; f, 2005.
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