Room/Suite Damage Responsibility Form

Room/Suite Damage Responsibility Form

Office of Residence Life
If damage has occurred in your room and/or suite over the course of your occupancy, any and all roommates/suitemates will be charged equally for the damage unless one individual takes responsibility for the damage. If you plan to take responsibility for any damages, please fill out the information below.
Name*

First NameLast Name
GMercyU Email*
reslife@gmercyu.edu
Cell Phone Number*

Area CodePhone Number
Building*
Room Number*
Description of the Damage - Be as specific and detailed as possible. Include the location of the damage in your room/suite. *
Upload an image of the damage if possible:

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By signing this Room/Suite Damage Responsibility Form I affirm that all the information provided is true and correct. I, the undersigned, am accepting responsibility for the room damage listed and I agree to be billed for the total costs associated with repairing that damage. I also understand that I may be billed for additional damages that were not attributed to one individual.
Signature*

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Date*

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Date
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