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2. Pool Adjustment Request Form
4. Date
   Date
6. Account Number
7. Phone Number
9. First Name
10. Last Name
12. Service Address
14. Date Pool was filled
    Date Pool was filled Start Date

    —

    Date Pool was filled End Date
15. Complete Fill or Top Off

    1. Complete
    2. Top Off
16. Gallon Capacity
18. Pool Shape

    1. Oval
    2. Round
    3. Rectangle

    1. Square
    2. In Ground
19. Length
20. Width
21. Depth
23. What was the meter reading before filling?
24. What was the meter reading after filling?
26. Information

    (PLEASE ALLOW (1) FULL BILLING CYCLE FOR CREDIT TO BE ISSUED)

    AN ANNUAL POOL ADJUSTMENT ON SEWER CHARGE IS AVALIBLE FOR CUSTOMERS WHO FII POOLS FOR NEW CONSTRUCTION, COMPLETE DRAIN, REFILL DUE TO REPAIRS, OR ANNUAL TOP OFFS. (INCLUDING REALTORS WITH HOMES FOR SALE.) WE DO NOT ISSUE A SECOND POOL ADJUSTMENT FOR TOPPING OFF POOLS ONCE A PRIOR ADJUSTMENT HAS BEEN RECEIVED. THE SEWER PORTION WILL BE ADJUSTED ON THE AMOUNT OF WATER CONSUMED FOR THE FILL. THE CUSTOMER IS RESPONSIBLE FOR THE FULL WATER PORTION. IT IS THE CUSTOMER’S RESPONSIBILITY TO HAVE THEIR BILL PAID BY THE DUE DATE.

    I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE.

28. Electronic Signature Agreement

    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.
30. Electronic Signature
Leave This Blank:


32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

* indicates a required field