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

Case1:05-cv-00066-JJF D0cument9 Filed 05/10/2005 Page10f3
` IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF DELAWARE
ANTHONY MICHAEL SMITH, )
Plaintiff, ;
v. g Civ. No. 05-066-JJF
DELAWARE DEPARTMENT OF g ‘`P ` _
CORRECTION, DR. ROBERTA ) D I
BURNS, FIRST CORRECTIONAL ) i j; I
LT' { . # i
§;3“§$§gE§E"E3§§EE$¥§N§EARNEY’ 3 I is mm ,
I“S““’“°“· ’ ». ~ F ,C_ I
D e f e nd a n t S . g i
AUTHORIZATION
I, Anthony Michael Smith, 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. § 19l5(b) and required by the
Court's order dated M3fd17· , 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 .·> , 2005.

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