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


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Pages: 3
Date: May 16, 2005
File Format: PDF
State: Delaware
Category: District Court of Delaware
Author: unknown
Word Count: 309 Words, 2,018 Characters
Page Size: Letter (8 1/2" x 11")
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Case 1:04-cv-01334-KAJ Document 8 Filed 05/16/2005 Page 1 of 3
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IN THE UNITED STATES DISTRICT COUR¤ ““l-SITSW; , a_ 1 4
ron THE DISTRICT or DELAWARE
· ti1 T _ »— A
_ DONALD JORDON, g _·
Plaintiff, )
)
v. ) Civ. No. 04-1334-KAJ
)
STATE OF DELAWARE, by and )
through the DELAWARE )
DEPARTMENT OF CORRECTIONS, )
STANLEY TAYLOR COMMISSIONER, )
PAUL W. HOWARD BUREAU CHIEF, )
BEN ROBINSON M.D. MEDICAL )
DIRECTOR, RICK KEARNEY WARDEN )
SUSSEX CORRECTIONAL ) -
INSTITUTION, ROBERTA BURNS )
M.D. STAFF PHYSICIAN, SUSAN )
RICHARDS ADMINISTRATOR OF )
HEALTH SERVICES, and JOHN AND )
JANE DOES I—XII, )
)
Defendants. )
AUTHORIZATION
I, Donald Jordan, SBI #095723, request and authorize the
agency holding me in custody to disburse to the Clerk of the
Court the initial partial filing fee of $8.49 and the subsequent
payments pursuant to 28 U.S.C. § l9l5(b) and required by the
Court's order dated yggga a;q;jg@%, 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

Case 1:04-cv-01334-KAJ Document 8 Filed 05/16/2005 Page 2 of 3
to any other agency into whose custody I may be transferred.
Date: {J lv A , 2 O 05 .
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