Leak Adjustment Request

This form is not a guarantee that a credit will be applied to your utility bill. You will be notified by mail if your request is either granted or denied. Only one leak adjustment will be allowed on one (1) billing period within a 12 month period and will only occur after all leaks have been repaired and verified by the City. The basis for a leak adjustment shall be the normal consumption under similar operating conditions.

Name

First NameLast Name

Account Number

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date leak was Discovered blanks Date
Date leak was fixed blank Date

Source of the Leak

Describe what was done to fix or correct the leak:

What type of documentation is being provided

Upload Documents Here

As the customer and/or owner for the above listed service address, I hereby notify the City of Fircrest Utility Billing Department that I have sustained a water leak and to the best of my knowledge the leak has been repaired. I am requesting consideration of a leak adjustment under the City of Fircrest Water Leak Adjustment Policy. I confirm that the above and any attached information is true and accurate. I also acknowledge and understand that only one water leak adjustment may be applied to my utility account in any 12 month period.

Signature