Application for High-Use Adjustment

Application for High-Use Adjustment
FORM:

APPLICATION FOR HIGH-USE ADJUSTMENT
Please Note - Shareholders must apply for a High-Use Adjustment within 30 days of receiving their first water bill that shows high-use.

* indicates a required field
Account Information
AMWC Account Number:*
Ex. 000000-000
Lot No
Service Address:*
Property Owner:*
(Shareholder)
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
Is this a mobile number?*

YesNo
Cell Phone
Business Phone
Do you have a landline?*

YESNO
Home Phone
E-mail*
Request Date:*

MonthDayYear
Date
Date High Use Began:*

MonthDayYear
Date
Repair Date:*

MonthDayYear
Date
Describe in detail, in the space below, what was done to repair the cause of the high water use and what you intend to do to prevent similar occurrences in the future.*

Requirements:

Proof of the repair is required and must be submitted with this application (itemized invoice from plumber, itemized receipt for repair parts, or other supporting proof), along with a sketch of the property showing the exact location of the high use.
- The high use must be at least two (2) times the average use for the prior two years for the month under consideration. You will be notified as to whether or not you meet that criteria and are eligible for a High-Use Adjustment. A maximum of one month of unusually high use will be considered for an adjustment.
- A High-Use Adjustment is not a credit of your entire bill. The adjustment amount will be 50% of the difference between the high water bill(s) and a water bill(s) based on average use.
- Only property owners may request a High-Use Adjustment. Tenants must have the property owner submit an application on their behalf. A property is eligible for one High-Use Adjustment in a 24-month period.
Attach supporting documentation (sketch of property showing location of leak, receipts for repair and/or invoice from plumber, etc.)

Upload a File
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Terms and Conditions
As property owner and shareholder of the above-noted property, I hereby apply for a High-Use Adjustment. I confirm information and attachments provided are true and accurate.
Please check:*

I agree to the above Terms and Conditions
Electronic Signature Agreement

By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement. By selecting "I Accept" using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature, or any resulting agreement between you and AMWC. In addition, you are confirming that you are the shareholder authorized to enter into this Agreement.
I Accept*

By checking this box and typing my name below, I agree to the terms and conditions of the Electronic Signature Agreement, and I acknowledge I am electronically signing my application.
First Name*
Middle Initial
Last Name*
Date*

MonthDayYear
Date
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