Water Leak Adjustment Request Form

Please note: Adjustments will be made only for leaks or breaks in lines underground or under structures.
Name:

Address:

Phone:

Email:

Date Water Leak Detected:
Date Water Leak was Repaired:
Please describe the water leak:

Please describe the repair that was made:

Repair Invoice or Receipt

Completion of this form does not guarantee an adjustment will be made to your water bill. All requests are evaluated based on your average water consumption for the billing period. In order to qualify for an adjustment, the leak must be repaired and copies of any invoices or receipts for repairs made along with this form must be submitted to prior to the next bill going out. If the form is not received within the time limit you will be responsible for the entire amount of leak consumption. The customer should keep their monthly bills current until the adjustment is made. No customer may receive more than two (2) adjustments in any twelve (12) month period. When all the criteria above has been satisfied, the City Manager, at his sole discretion, may approve an adjustment.
By checking this box you attest that you understand the conditions of the program and that all information provided is true.
Electronic Signature (typed name of person submitting the form)