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2. Before filling out this form, please review How to Check for a Leak (PDF).
   After repairs have been made, you may be eligible for an adjustment on your City Utility bill.
4. Account Information
6. Utility Account Number*
8. Service Address*
10. City*
11. State*
12. Zip Code*
16. Customer Information
18. First Name*
19. Last Name*
21. Contact Phone Number*
22. Email Address
26. Leak Information
28. Date you found out about the leak, if unknown please estimate
    Date you found out about the leak, if unknown please estimate
29. If the leak has been repaired, on what date was the repair completed?
    If the leak has been repaired, on what date was the repair completed?
31. Has the leak been repaired?*

    1. Yes
    2. No
33. Where was the leak located:*
    *inside/outside the home - give as much specificity as possible*
35. Give any information that would be helpful regarding the leak:
37. Agreement and Signature
    By submitting this application, I understand that bill adjustments are not guaranteed. Leak repairs must be made within six months to be eligible for consideration of an adjustment. A review of your water usage history will determine the amount of any adjustment, if given. Billing adjustments may take one to three months to appear on your utility statement. You are responsible for the full bill amount prior to adjustment. Failure to pay your city utility bill may result in disconnection of water service and additional service fees. Charges continue to accrue whether or not the water meter is off.
39. I have read and agree with the conditions written above.*

    1. I agree.
41. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
43. Electronic Signature*
44. Date*
    Date
Leave This Blank:


46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit

* indicates a required field