Bal Harbour Village Hall · 655 – 96th Street, Bal Harbour · Florida 33154 · (305) 866-4633 · Fax (305) 868-6575
Library Card Reimbursement Request Form
Bal Harbour Village reimburses residents for a maximum of two library card purchases per household. Eligibility is based
on an annual basis effective on the date library cards are issued. Please note that refund checks are mailed to the Bal
Harbour address applicant provides.
Please submit the following documents.
Personal Information
First Name: Last Name:
Street Address:
City: State: Zip Code:
Home Phone: Cellular Phone:
E-mail Address:
Have you requested a library card reimbursement before? Yes No
Library Card(s) Information
Name of Cardholder #1: Amount Paid $
Card Number: Date Issued:
Name of Cardholder #2: Amount Paid $
Card Number: Date Issued:
Total Reimbursement
Request
$
I hereby acknowledge that the information I have provided is true and correct, that I am a current Bal Harbour
Village resident, and that I am entitled to receive reimbursement for up to two library cards issued by Miami-Dade
Public Library System per household. Furthermore, I authorize the Village to mail a refund check to the address
listed above.
Applicant’s Printed Name: ________________________________________________________________________
Applicant’s Signature: ____________________________________________ Date: _________________________
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OFFICIAL USE ONLY
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Validated by (Print Name):
Signature: Date:
Village Manager’s Signature: Date:
State Issued Photo Identification
Proof of Bal Harbour Village Residency
Receipt(s) of Miami-Dade County Library Card Purchase
Completed Library Card Reimbursement Request Form
Date:
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