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

!Case1:O4-cv-00958-KAJ DOcument18 Filed 08/O3/2005 Page10f2
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF DELAWARE
PEDRO A. RODRIGUEZ, )
j Plaintiff, g
v. g Civ. NO. 04-958-KAJ
? FCM OR FIRST CORRECTIONAL g
i MEDICAL, and THE DELAWARE ) y · · ¤ur-;se~,—a;s-»·rr. --» ¤ .
- DEPT. or CORRECTIONS, > z _ q _
F Defendants. g L i _,, _ g w , . i i
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' AUTHORIZATION . I
=I
k I, Pedro A. Rodriguez, request and authorize the agency
i holding me in custody to disburse to the Clerk of the Court the
3 initial partial filing fee of $12.83 and the subsequent payments
pursuant tO 28 U.S.C. § l9l5(b) and required by the Court's Order
5 dated October 25, 2004.
This authorization is furnished in connection with the
J filing of a civil action, and I understand that the filing fee
tz for the complaint is $150.00. I also understand that the entire
S filing fee may be deducted from my trust account regardless of
j the outcome of my civil action. This authorization shall apply
f to any other agency into whose custody I may be transferred.
Date: und , 2005;
F
J
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Case1:O4-cv-00958-KAJ D0cument18 Filed 08/O3/2005 Page20f2
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