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Case 1:12-cv-04521-LAP Document 2-2 Filed 07/25/12 Page 1 of 1

UNITED STATES DISTRICT COURT
SOUTHERN DISTRICT OF NEW YORK

PRISONER AUTHORIZATION

Case Name:

____________________________________v.____________________________________
(Enter the full name of the plaintiff(s))

(Enter the full name of the defendant(s))

Docket No: No. _____ Civ. _______ ( )

(Enter the docket number, if available; if filing this with your complaint, you will not have
a docket number.)

The Prison Litigation Reform Act (“PLRA” or “Act”) amended the in forma pauperis statute (28
U.S.C. § 1915) and applies to your case. Under the PLRA, you are required to pay the full filing fee when
bringing a civil action if you are currently incarcerated or detained at any facility. If you do not have
sufficient funds in your prison account at the time your action is filed, the Court must assess and collect
payments until the entire filing fee of $350.00 has been paid, no matter what the outcome of the action.

SIGN AND DATE THE FOLLOWING AUTHORIZATION:

I, _______________________________________ (print or type your name), request and authorize
the agency holding me in custody to send to the Clerk of the United States District Court for the Southern
District of New York, or, if this matter is transferred to another district court, to the Clerk of the transferee
court, a certified copy of my prison account statement for the past six months. I further request and
authorize the agency holding me in custody to calculate the amounts specified by 28 U.S.C. § 1915(b), to
deduct those amounts from my prison trust fund account (or institutional equivalent), and to disburse those
amounts to the United States District Court for the Southern District of New York. This authorization shall
apply to any agency into whose custody I may be transferred, and to any other district court to which my
case may be transferred and by which my poor person application may be decided.

I UNDERSTAND THAT BY SIGNING AND RETURNING THIS NOTICE TO THE COURT,
THE ENTIRE COURT FILING FEE OF $350.00 WILL BE PAID IN INSTALLMENTS BY
AUTOMATIC DEDUCTIONS FROM MY PRISON TRUST FUND ACCOUNT EVEN IF MY CASE
IS DISMISSED OR EVEN IF I VOLUNTARILY WITHDRAW THE CASE.

_______________, 20___
Date signed

rev. 01/11

___________________________________________

__________________________________________

Signature of Plaintiff

Prisoner I.D. Number

___________________________________________________

Name of current facility