Library Fine, Fee, and /or Other Charge Appeal Form

First Name

Last Name

Middle Name

Mailing Address

Physical Address

Tel No

BirthDate

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 library fine, fee, and/or other charge assessed to my account for the reason listed below.

SIGNATURE OF signatureOfAnApplicantAPPLICANT

Date