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2. Customer Name*
3. Account #*
5. Phone Number*
6. E-Mail
8. Address*
9. City*
10. Zipcode*
12. Billing Dates Requesting Adjustment*
14. Service Address*
16. Location/Details of Leak*
18. Upload Related Documents Below
19. Upload Related Documents Here
21. Electronic Signature*

    I attest that the leak, for which this billing adjustment is being prepared, has been repaired: attached hereto is a copy of proof that said repairs were completed (plumber's invoice or receipt for parts/labor with detailed statement of leak and measures taken to fix leak). The owner has a responsibility to repair the leak within 30 days of being notified of the leak to qualify for a leak adjustment. If a leak affects more than one billing cycle, then both billing cycles will be adjusted accordingly. 

22. Date*
    Date
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24. 1. Receive an email copy of this form.
25. Email address

    This field is not part of the form submission.

26. Submit

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