Before completing this form, please review the Water Leak Adjustment Policy which outlines the conditions for which a leak adjustment is allowed.  By submitting this form you acknowledge you have read the Policy. 

Address Where Leak Occurred:

Customer's Name:

 

 *

Customer's Phone Numberext.

  

Customer's Address (if different from where leak occurred):

Email:

  

Describe leak, location, and repairs made:

  

Date customer became aware of leak:

 

How customer became aware of leak:

Date City was informed leak was repaired:

Other Information:

I request that my water/sewer bill be adjusted.  I understand that while consideration of this request is pending, I am responsible to make a payment equal to the amount of the last previous unchallenged bill plus one half of the difference between the water charge on the challenged bill and the average water charge in order to avoid a late fee.  Water Leak Adjustment Policy

By submitting this form, I CERTIFY that all statements and information furnished on this form are true, complete and correct to the best of my knowledge and belief, and are made in good faith.  I understand that statements or information furnished on this form are subject to verification and I agree to furnish supporting documents or information when so requested and/or names, addresses and phone numbers (if known) of officials or other individuals who can substantiate the above information.  I also understand that intentional misstatements or falsification may result in disciplinary action.

 

Signed

Date

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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