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

Case 1 :05-cv—00219-KAJ Document 15 Filed 10/14/2005 Page 1 of 2
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF DELAWARE
KEVIN SIDNEY EPPERSON, )
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Plaintiff, ) f
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v. ) Civ. No. 05-2l9—KAJ · ‘
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COMMISSIONER STANLEY TAYLOR, ) ` _"
WARDEN THOMAS CARROLL, DENTAL ) FI Llgij
DEPARTMENT, DENTIST WOMAN, ) -
and APPOINTMENT WOMAN, )
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Defendants. ) LC; 1%"""
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usLT;jgF.. K.,. · E
AUTHORIZATION DW-*@ -· ..
I, Kevin Sidney Epperson, request and authorize the agency
holding me in custody to disburse to the Clerk of the Court the
initial partial filing fee of $6.00 and the subsequent payments
pursuant to 28 U.S.C. § l9l5(b) and required by the Court’s order
dated /‘°{:.ZL{C·5/ , 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: C9 Q.\ IS` , 2005.
Kevin Sidney Eppe on

Case1:O5-cv—OO219-KAJ D0cument15 Fi|ed10/14/2005 Page20f2
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