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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
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