Household Info
ZIP Code
*
Home Type
*
House
Apartment
Mobile Home
Other
Do you own or rent your property?
*
Own
Rent
Number of Household Occupants
*
1–2
3–4
5+
Water Bill Experience
Average Monthly Water Bill
*
Under $50
$50–$99
$100–$149
$150+
Has your water bill increased recently?
*
Yes
No
Not sure
How often are your bills unusually high?
*
One-time
Sometimes
Often
Almost every month
Possible Issues
What do you think caused the high bill?
*
Leak (inside or outside)
Old pipes or plumbing
Meter or billing issue
Service interruptions
Not sure
Did you report the issue to the water utility?
Yes
No
If yes, was it resolved?
*
Yes
No
Still Waiting
Impact & Help
Has the high bill caused financial hardship?
Yes
No
Have you received a shut-off notice?
Yes
No
What help would be most useful?
*
Leak repair help
Bill review or audit
Payment plans
Lower or income-based rates
Better communication from utility
Home Maintenance
In the winter, do you feel drafts coming from any of the following?
*
Windows
Front/Back doors
Electrics Outlets
Attic Access/Hatch
Are there any urgent repairs your home currently needs?
*
Roof leaks
Window replacement
Insulation
HVAC/Heating system repair
Other
Which topics would interest you most? (Select top 2)
*
Sealing air leaks (caulking and weatherstripping)
Insulating pipes and water heaters
Managing attic and basement airflow
Understanding your energy bill
Optional Feedback
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