Leak Adjustment

Please read the requirements for completing this form:

All information below must be completed in detail for consideration
Required documentation must be submitted with application (see below)
The customer is responsible for all billings until receipt of written notification of leak adjustment credit or denial.
All leaks must be repaired.

Account Number:

Customer Name*

First Name

Last Name

Current Email Address*

Service Address*

Daytime Phone Number*

Description of the leak and what repairs were made*

How was the leak discovered?*

What date was the leak discovered?*

What date was it repaired?*

Who repaired the leak?*

If a plumber repaired the leak, a bill on printed letterhead detailing materials and labor (if plumber’s bill is not on letterhead, bill must have plumber’s state certification number).
If repairs are made by someone other than a licensed plumbing company, they must be supported by receipts for purchase of repair parts.

Please upload acceptable documentation

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Signature - I certify that this application and attached documents contain no false statements.*

Use your mouse or finger to draw your signature above