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2. Account Number*
3. Customer Number
5. Name on the Account*
6. Service Address*
8. Is the mailing address same as the service address?*

   1. Yes
   2. No
9. Mailing Address*
11. Phone Number*
12. Email Address
14. Which month's bills were affected by the leak? *
16. List relevant facts for credit adjustment (date of repair, what was repaired, etc..)*
18. Upload your receipt

    Receipts for repairs or parts must accompany a leak adjustment request.

    
    

20. 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.

22. Electronic Signature
Leave This Blank:


24. 1. Receive an email copy of this form.
25. Email address

    This field is not part of the form submission.

26. Submit

* indicates a required field