Housing Petition

Date:

Last Name: N-Number:

First Name: MI:

Building: Room:

Daytime Phone:

E-Mail Address:

Address to mail results to:

I am petitioning for: (Check all that apply)

Removal of Late Fee

Removal or Reduction of Damage Charge(s)

Removal or Reduction of Cleaning Charge(s)

Removal of Improper Check-Out Charge

Removal of Key Charge

Other, please specify

My Petition is as follows: