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

· Case 1:05-cv—OOO37—SLR Document 11 Filed O4/25/2005 Page 1 of 2
1 IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF DELAWARE
HARRY SAMUEL, )
1
Plaintiff, )
1
v. ) Civ. No. 05-037-SLR
)
THOMAS CARROLL, LT. PORTER, 1 gyg_ mV____MwWJ
COUNSELOR KRAMER, I.s.c.c. 1 ` " ‘
(THE CLASSIFICATION 1 »tA1{_gq§payh i
COMMITTEE}, and DENTAL ) M i g
SER"ICE# g » R
D€f€“da“tS‘ ) f .. I R ·· - ~,,..,.
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AUTHORIZATION mh H
I, Harry Samuel, request and authorize the agency holding me
in custody to disburse to the Clerk of the Court the initial
partial filing fee of $11.85 and the subsequent payments pursuant A
to 28 U.S.C. § 1915(b} and required by the Court’s order dated 1
(lgjgé [Q , 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 y
1
to any other agency into·whose custody I may be transferred. E
Date: pg .,Fgg Q {S , 2005. 1
.1AR. 2. 4&eA¤*,.v;· 1
Harry .muel ]
1
I1
1

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