Dear Concerned Patron:

Please help us by detailing below your reasons for disputing the Circulation fine on your library account. Once completed, this form will be referred to the Coordinator of Circulation Services for a prompt decision and action regarding your concerns.

Name: Date:

I'm a regular e-mail reader. Please contact me at:

OR

It is best if you phone me at:

Title:

Amount of Fine = $

Title:

Amount of Fine = $

Title:

Amount of Fine = $

Please briefly describe the problem and/or the reasons why you wish to dispute the fine charged to your library account. Please be as specific as possible. Thank you for your concern and patience in this matter!