Billing Appeal Form

If you have a question/concern about a Library Billing matter or you wish to appeal/contest a bill, please complete this form. A Library staff person will soon contact you.

First Name *

Last Name *

Library Barcode Number *

Enter the number from your ID. Example: 22106007679833.

Phone Number

Email Address *

Type of Checkout Billed *

General Collection

Interlibrary Loan (ILL)

Reserves (including Laptops and equipment)

Media Center and DSC equipment

For each item, please enter the TITLE, BARCODE and CALL NUMBER (ex. Title: The Grapes of Wrath, Item Barcode Number: 32106014060575, Item Call Number: PS3537.T3234G8 1967)

NOTE: For ILL items, please include the TITLE and the ILL NUMBER located on the bookstrap or overdue notice. (ex. Title: The Grapes of Wrath, Item Barcode Number: ILL #5864795)

Item #1

Title

Item Barcode Number

Item Call Number

Add Additional Items

Add Item #2

Title

Item Barcode Number

Item Call Number

Add Item #3

Title

Item Barcode Number

Item Call Number

Add Item #4

Title

Item Barcode Number

Item Call Number

Add Item #5

Title

Item Barcode Number

Item Call Number

Add Item #6

Title

Item Barcode Number

Item Call Number

Add Item #7

Title

Item Barcode Number

Item Call Number

Add Item #8

Title

Item Barcode Number

Item Call Number

Add Item #9

Title

Item Barcode Number

Item Call Number

Add Item #10

Title

Item Barcode Number

Item Call Number

If you have more than 10 items to appeal, please submit the first 10 here and then return to this form and resubmit it with the remaining items.

Reason for Appeal

If you are appealing more than one item and the status is different for each item, please use the Explanations/Comments area below.

I am appealing my bill because:

I returned the item(s) before the due date

I question the amount of fees assessed

I need more information about my bill

Other reason for appeal

Date Returned

Month

Day

Year

Fees Assessed $

Please specify

Explanation/Comments

Leave this field blank

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Billing Appeal Form

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Billing Appeal Form

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