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Request for Evaluation of Water / Sewer Bill

2. Date
   Date

3. Billing Date
   Billing Date

5. I hereby request a review of the charges for water and/or sewer usage:

7. Account Name

8. Account Number

10. Service Location

12. Contact Name

13. Contact Phone Number

17. Choose one:

    1. I believe that the amount charged is inaccurate.
    2. I believe that the measurement of the amount of water used was inaccurate.

19. Please explain.

23. Check all that apply:

    1. I examined our system from the meter, through all pipes and fixtures.
    2. A licensed plumber examined our water system.
    3. A leak was not discovered.
    4. A leak was discovered.

25. Date of Licensed Plumber's Inspection
    Date of Licensed Plumber's Inspection

26. Plumber's Name / Company

28. Location of Leak

30. I am hereby requesting a sewer credit in the amount billed due to this discovered leak. Documentation is required for credit.

    1. I agree.

32. Leak was repaired by:

33. Leak was repaired on:
    Leak was repaired on:

35. Credit Approved?

    1. Approved
    2. Denied

37. Water Credit Amount

38. Total Credit Amount

40. Reason

42. Authorized By:

44. Date Posted to Utility Billing
    Date Posted to Utility Billing

45. New Balance

47. Version 2019-04-16

    Version 2019-04-16

Leave This Blank:


49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit

* indicates a required field