Request for Utility Bill Review, Adjustment, or to Petition the Utility Billing Review Committee (UBRC)
Account Holder Name
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First Name
Last Name
Service Street Address
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Street Address
Street Address Line 2
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email
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example@example.com
Account Number
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Please provide the account number exactly as it appears at the top of your utility bill
Format: 000000-000000.
How many utility bills are you requesting for review or adjustment?
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Please Select
1 Utility Bill
2 Utility Bills
Please provide the date of the utility bill for review or adjustment
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Month
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Day
Year
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Please provide the date of the 2nd utility bill for review or adjustment
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Month
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Day
Year
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Please select the reason for review or adjustment:
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1. Repair of involuntary leak: Documentation must include type & date of repair (i.e., plumber invoice, receipt/pictures of proof of supplies purchased/repair).
2. New or repaired permitted swimming pool: Documentation must include type of repair & number of gallons used to fill/refill pool (i.e., plumber invoice, receipt/pictures of proof of supplies purchased/repair). Pools must be properly permitted pursuant to law.
3. Flooded structure during a hurricane/flooding event (for pool related issues select #2 above): Damages must be recorded through FEMA (i.e., insurance claim documents).
4. High bill in absence of a leak with a mechanical water meter: For mechanical water meters only. Documentation must include certification from a licensed plumber or leak detection company showing absence of leak of private property.
5. Abnormal event (for leaks select #1 above): No documentation required.
6. Utility Billing Review Committee (UBRC): Documentation must include written department decision. Provide reason for petition under Additional Comments below.
Repair date required
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Month
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Day
Year
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Pool fill/refill date required
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Month
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Day
Year
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Additional Comments
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By submitting this request, you affirm that all information on this application form is true and correct to the best of your knowledge.
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