REQUEST FOR REIMBURSEMENT FOR MATERIAL LOST IN DELIVERY
(One item per form! Type/print Library Name & Address and copy form.)
Reimbursement is made on a semi-annual basis for claims as listed below:
| Claim Period in which Material Lost | Claims Due at Regional Office | Reimbursement Made |
| October - March | July 15th | August |
| April - September | January 15th | February |
Example: Book sent/lost in Regional Delivery Service October 2000. Claim must be filed by July 15, 2001. This is more than three months after the loss and within the six month claim period.
Today's Date_________________________________ Date of Loss_________________________________
Name of Library_____________________________________________________________________________
U S Mail Address____________________________________________________________________________
City, State, Zip______________________________________________________________________________
Type of Material_____________________________________________________________________________
Title_________________________________________________________________________________________
Author_______________________________________________________________________________________
Date our library shelves were last checked_________________________________________________________
Date other library's shelves were last checked______________________________________________________
Reimbursement will be made at a rate divided proportionally among all claims at standard item prices listed below. Please check the appropriate description:
| Hard Cover | - Adult | $20.00 | __________ |
| - Juvenile | $15.00 | __________ | |
| Paperback | - Trade (Fodors, College Guides) | $12.00 | __________ |
| - Other | $5.00 | __________ | |
| Periodicals/Pamphlets.Government Documents | $3.50 | __________ | |
| Audiovisual | - Cassette | $5.00 | __________ |
| - CD | $10.00 | __________ | |
| - DVD | $25.00 | __________ | |
| - Video | $25.00 | __________ | |
| - Mixed Media Kit | $25.00 | __________ | |
Certification of Loss in Delivery
(claim must be made by owning library)
Signature__________________________________________________________________
Title of person completing this form________________________________________________
Make check payable to__________________________________________________________
| Mail forms to: | Highlands Regional Library Cooperative |
| 400 Morris Avenue, Suite 202 | |
| Denville NJ 07834 |