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Run: Fine and Fee Waiver Request Form (Library)

Use this Fine and Fee Waiver Request Form to collect a patron’s account details, the charge in question, and the reason for a waiver request in one place. It...

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Patron Information

Full Name (required)

Library Card Number (required)

Enter the barcode number printed on your library card.

Email Address (required)

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 (required)

Fine or Fee Details

Type of Charge (required)

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) (required)

Enter the total dollar amount you are requesting be waived.

Amount You Are Requesting to Be Waived (in USD) (required)

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 (required)

Please describe your situation in detail (required)

Provide as much relevant context as possible. Staff will keep this information confidential.

Do you have supporting documentation to attach? (required)

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. (required)

Yes No N/A

I consent to the library retaining this request and any supporting documents as part of my patron account record for administrative and audit purposes. (required)

Your information will be used solely to process this waiver request and will not be shared with third parties except as required by law.

Yes No N/A

I understand that submitting this form does not guarantee a waiver will be granted, and that the library's decision is final. (required)

Yes No N/A

Date of Submission (required)

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.

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Email (required)

Your name (optional)

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