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Leak Adjustment Request Form
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Steps
1.
Step One
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2.
Step Two
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Step One
Leak Adjustment Request Form
Complete this form, clearly stating the reason for the leak adjustment request. Please make sure you attach any plumber receipts/or receipts for parts purchased for repair. An adjustment shall only be considered for consumption above the average usage. Please allow 30 days for your account to be reviewed.
Account Information
Date Requested
*
Date Requested
Account Number:
*
Account Holders Name
*
Address
*
City
*
State
*
Zip Code
*
Phone #
*
Alternate Phone #
Date Leak Discovered
*
Date Leak Discovered
Date of Repair
*
Date of Repair
Continue
Step Two
Type of Leak
*
Toilet
Bathtub/Shower
Irrigation
Water Heater
Busted Pipe
Spigot
External Line
Other
Description of Leak and Completed Repairs:
*
Repairs Completed by Customer\Plumber:
Attach a copy of repair invoice or receipt for parts purchased
Incomplete Leak Adjustment Request Forms will be returned to the customer without review for adjustment.
Signature
*
First and Last Name
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Email address
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