Leak Adjustment Request Form

Leak Adjustment Request Form

Leak adjustments are currently offered 1 time a year. The leak must be caused by a broken pipe or line. No adjustments will be made from water left running or swimming pools. A copy of a repair bill or parts purchased bills must be uploaded before a leak adjustment request will be considered. Submission of this leak adjustment request, does not mean the request is approved. You will receive a confirmation from our office of approval or denial of request. Leak must have been in the last 60 days. Adjustment will be added to the account no refund will be given to the customer. Adjustments are typically 1/2 of the water portion of the bill, but will not be adjusted below an average bill for the account. Jefferson RWD # 1 will not pay for the repairs or parts.
Customer Account Number*
Email*
example@example.com
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Was the high useage caused by a busted or broken pipe/line ?*

YesNO
Who made the repairs on the leak?*

SelfPlumber
What is the approximate date the usage occurred?*
Please provide a brief description of the leak and repairs made*
Please upload a copy of the plumber repair bill and/or parts bill.

Cancelof
By signing below I attest that I am the owner/tenant of the account and the high useage I am requesting an adjustment for was a leak and has been repaired in a timely manner. I understand that submitting this request does not mean the request is approved. I will receive an approval or denial from the Jefferson County Rural Water office.
Signature

Clear
Should be Empty: