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

Case 1:05-cv-00051-G|\/IS Document 11 Filed 05/O2/2005 Page 1 of 2
IN TEE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF DELAWARE Zw5HAy_2 PH h:08
JIMMIE LEWIS, )
Plaintiff, g
v. g Civ. NO. 05-O5l—GMS
STANLEY TAYLOR AND STAFF, g
RAPHAEL WILLIAMS AND STAFF, }
and FIRST CORRECTIONAL )
MEDICAL AND STAFF, )
Defendants. g
AUTHORIZATION
I, Jimmie Lewis, 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
[ki-fmézé , 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: ‘¥[ T }Q , 2005.
g / j;_, . .i
J`@Fie Lewis 1--

Case1:O5—cv-00051-GMS D0cument11 Filed 05/O2/2005 Page20f2
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