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3. 
5. Customer Information
7. Today's Date *
   Today's Date
9. Customer Name *
11. Account Number *
13. Email Address*
15. Phone Number *
17. Service Address*
19. Date of Incident(s)*
    Date of Incident(s) Start Date

    —

    Date of Incident(s) End Date
21. Description of Damage*
23. Please upload a copy of your repair receipt*
25. Customer Agreement
27. By signing this request, I understand and agree to the following:
    • Submission of this document does not automatically qualify my account for an adjustment and my request will be reviewed by a Utility Billing Representative for approval.
    
    • During the review process my request must meet certain qualifications specified in the City Ordinance to receive an adjustment.
    
    • I am responsible for submitting all repair tickets/receipts to Utility Billing to show the date and type of repair completed.
    
    • During the review of my account, I am responsible to pay or make payment arrangements with regards to the balance on my account.
    
    • If I am currently enrolled in automatic payments, the full balance will be processed on the due date. If this is not the desired result, please contact the Utility Billing office to be removed from automatic payments (You will be required to re-enroll after the adjustments, if any, have been made).
    
    • To receive my adjustment, the bill must have already been generated showing the abnormal consumption and the current consumption is required to be reading at a normal rate again. No adjustments will be made prior to the bill generation.
    
    • Process time for my adjustment could be up to 14 business days after submission or bill generation (If request is received before bill generation, then the response will be 14 business days after the bill is generated) and I will receive notification of the status and result of my request in writing via email on or after the 14 business days.
29. Signature *
31. *Payment Assistance

    If you are having difficulty paying your water bill, click here for resources to assist our residents with payments.

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

    This field is not part of the form submission.

35. Submit

* indicates a required field