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2. Complete this form to request an adjustment on your water bill if you had a water leak. This adjustment is only allowed once per calendar year. *NOTE: Adjustments are figured off of a twelve month average. If customer does not twelve months history they may not be eligible for a full adjustment.*

4. Customer/ home owner*
5. Email Address
7. Service Address*
9. City
10. State
11. Zip Code
13. Phone Number*
14. Individual/ Plumbing Company*
16. Date repair was completed.*
    Date repair was completed.
20. **NOTE**

    If the required information is not completed as requested, there will be a delay in completion of adjustment to account until requested information is received. 

22. Please be specific, What/ Where the leak was and What was repaired.*
24. Electronic Signature Agreement*

    By signing this online form, I/we are agreeing that the information provided by I/we is correct and now the repair is in good working condition. 

    In my opinion these leaks were large enough to have caused the increase in the water bill rendered to the above address. I make an oath the statement above is true and correct. 

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
26. Electronic Signature*
27. Date*
    Date
Leave This Blank:


29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit

* indicates a required field