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2. First Name*
3. Last Name*
4. Email Address
6. Service Address*
8. Service Address Line 2
10. City*
11. State*
12. Zip*
14. Phone Number*
15. Account Number*
17. Date of Repair (dd/mm/yyyy)*
18. Date Leak Detected (If Known) (dd/mm/yyyy)
20. Type of Leak*
22. If interior leak, did the water flow to a drain?*

    1. Yes
    2. No
23. Invoice of Repair/Receipt
    Please provide copy of invoice of repair or receipt for parts purchased to correct the leak. Water usage must return to previous average before determination of your adjustment will occur. Additional billing may need to occur to establish an average for the account.
25. Digital Signature *

    1. By checking this box, I agree to the below conditions.

    I understand that completion of this form does not guarantee a water/sewer adjustment will be given. I also understand that all documents, including repair receipts, must be received before my account will be reviewed for a leak adjustment. I also certify that all the information submitted is true and correct and applies to the account for which the credit is sought.
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27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit Submit and Print

* indicates a required field