Appeal of Decision on Library Fine, Fee, and/or Other Charge Appeal Form

FIRST NAME

LAST NAME

MIDDLE NAME

MAILING ADDRESS

PHYSICAL ADDRESS

TELEPHONE NUMBER

BIRTHDATE (MONTH/DAY/YEAR)

UTAH DRIVER LICENSE OR ID NUMBER

EMAIL

EMERY COUNTY LIBRARY SYSTEM CARD NUMBER

TOTAL AMOUNT OF FINE, FEE, AND/OR OTHER CHARGE

NUMBER OF ITEMS

TYPE OF ITEM(S) FOR WHICH FINE, FEE, AND/OR CHARGE ASSESSED:

I am appealing the branch librarian’s decision regarding the library fine, fee, and/or other charge assessed to my account for the reason listed below.

Date

Signature of an Applicant