Fillable HousingChargeForm09-02-11 - Housing Charge Form

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HousingChargeForm09-02-11 - Housing Charge Form

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HOUSING CHARGE FORM
NAME: ______________________________ ID NUMBER:_________________
Please make the following adjustment of room charges as of __________________
due to ____ judicial sanction, ____ fine ____ damage, ____ private room or other:
__________________________________________________________________.
Please list a thorough description of the charges and the exact amount of the
fine/damage.
Description Amount Dorm Fine/Damage
___________________________ __________ _____________ __________
___________________________ __________ _____________ __________
___________________________ __________ _____________ __________
Action taken:________________________________________________________
__________________________________________________________________
__________________________________________________________________
_____________________________________ __________________
Student Signature (if applicable) Date
_____________________________________ __________________
Staff Signature Date
Reduce ____________ -- $ __________. Charge ____________ -- $ __________.
Reduce ____________ -- $ __________. Charge ____________ -- $ __________.
Reduce ____________ -- $ __________. Charge ____________ -- $ __________.
Action taken:________________________________________________________
__________________________________________________________________
__________________________________________________________________
_____________________________________ _____________________
Director of Payroll & Special Services Date
Revised 9/11
ATU AVP 2000-2
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HousingChargeForm09-02-11 - Housing Charge Form

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Completed 17 March 2020

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