Fine and Fee Waiver Request Form (Library)

A form for library patrons to request a waiver of outstanding fines or fees, providing their account details, reason for the request, and supporting context, with staff review and approval workflow.

Patron Information

• Full Name
• Library Card Number
  Enter the barcode number printed on your library card.
• Email Address
  We will send the decision notice to this address.
• Phone Number (Optional)
  Provide a phone number if you prefer to be contacted by phone.
• Preferred Contact Method

Fine or Fee Details

• Type of Charge
  Select all that apply.
• If 'Other', please describe the charge type
• Title(s) of Item(s) Involved
  List the title(s) of the book, DVD, or other material(s) associated with the charge, if known.
• Total Amount Owed (as shown on your account, in USD)
  Enter the total dollar amount you are requesting be waived.
• Amount You Are Requesting to Be Waived (in USD)
  If you are requesting a partial waiver, enter the amount here. Otherwise, enter the same amount as above.

Reason for Waiver Request

• Primary Reason for Request
• Please describe your situation in detail
  Provide as much relevant context as possible. Staff will keep this information confidential.
• Do you have supporting documentation to attach?
  Examples: medical bill, utility shutoff notice, return receipt. Documentation is helpful but not required.
• Upload Supporting Documentation (Optional)
  Accepted formats: PDF, JPG, PNG. Maximum file size: 10 MB per file. Do not upload documents containing your Social Security Number or full financial account numbers.

Patron Acknowledgment and Consent

• I certify that the information provided in this request is accurate and complete to the best of my knowledge.
• I consent to the library retaining this request and any supporting documents as part of my patron account record for administrative and audit purposes.
  Your information will be used solely to process this waiver request and will not be shared with third parties except as required by law.
• I understand that submitting this form does not guarantee a waiver will be granted, and that the library's decision is final.
• Date of Submission
  Enter today's date.

Staff Use Only

• Reviewing Staff Member Name
• Date of Review
• Decision
• Amount Approved for Waiver (in USD)
  Enter the dollar amount approved. Leave blank if denied.
• Staff Notes / Justification
  Document the rationale for the decision for audit trail purposes.
• Policy or Authority Referenced
  Cite the library policy or authority under which this decision is made.