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

First Name

Last Name

Middle Name

Mailing Address

Physical Address

Phone Number

Date of Birth

Utah Driver License or ID Number

Emery County Library System Card Number

Total Amount of Fine, Fee, and/or Other Charge

Number of Items

Type of Items for Which Fine, Fee, and/or Charge Assessed

AUDIO-BOOK

BOOK

CHROMEBOOK

DVD/BLU-RAY

FIRE TABLET/KINDLE

PERIODICAL

PLAYTIME PAD

STORYTIME BAG

OTHER

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

Signature of Applicant

Date