REQUEST FOR WATER/SEWER LEAK ADJUSTMENT

Name on Account:______________________________________________________Account Number:_______________________
Contact Phone No#:___________________________ServiceAddress:__________________________________________________
Mailing Address:_____________________________________________________________________________________________

Type of Adjustments Requested: 
                                                                                               ____ 100% Adjustment Water  (once per history of ownership of property)
___ 50% Adjustment Sewer(once per year)                          ____ 100% Adjustment Sewer (once per history of ownership of property)
 	
Date Leak Discovered:___________________________Date Leak Repaired:________________________________________________
Description of Leak:______________________________________________________________________________
____________________________________________________________________________________________

Repaired by (documentation attached) 
_________ Customer                 ___________Contractor

PLEASE NOTE:  Completion of this form does not guarantee adjustment will be made to your bill.  All adjustments are issued based on average usage for previous account history and are credited on your bill.  Once the review is complete, you will receive notification of results from the Utility Billing Office.  We cannot guarantee approval/disapproval on current bill.  Please return the completed application to Washington Municipal Utilities, 2100 Memorial Ave., P.O. Box 800, Washington, IN  47501with required documentation.

I have read, understand, and agree with the leak adjustment guidelines.

Signature:_______________________________________ Date Submitted:________________________ 

Property Owner Signature ________________________________________
        
For Office Use Only

	Date Received 	Receipts and/or Photos: 
Yes_______       No_________	
Billing period of leak

	Usage on Original Bill	Average Usage            	
Adjusted Units/Total Leak Credit                    

	Approval Date                           	Denial Date                                                 	
 Invoice Number

	Approval	Denial