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2. Customer Name
3. Service Address
5. Phone Number
6. Utility Account Number
8. Description of Leak
   (i.e. leaking toilet, broken pipe, etc.)
10. Date Leak Was Repaired
    Date Leak Was Repaired
12. Repair Documents*
    Attach a copy of all repair documents (i.e.Receipt from Plumber).
14. Signature*

    Please allow up to 30 business days to process this request, possibly longer if the consumption does not go down in the first 30 days. The city will adjust a maximum of two bills per calendar year. If the city determines that any information contained in this statement is false, you will be re-billed for the amount of the adjustment which may result in interruption of city service(s). The total amount of your utility bill is your responsibility to pay by the due date. If you need additional time to pay, please contact customer service to make a payment arrangement.

    1. I agree
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16. 1. Receive an email copy of this form.
17. Email address

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