City of Cibolo
REQUEST FOR SEWER AVERAGE ADJUSTMENT
O
ffice Use: Approved Denied ____________________________________
Describe Situation or Repairs Made:
___________________________________________________________________
___________________________________________________________________
Please read and acknowledge each item below by checking the box and signing:
____ Adjustments will be processed after evidence of repair is reflected by reduced consumption in the
following billing period.
____ The customer will be required to pay an amount equal to the most recent undisputed billed
amount by the due date, pending the adjustment calculation.
____ Adjustment calculation will consider customer consumption for the same time period for the prior
year (or other relevant time period if that data doesn’t exist).
S
ignature:__________________________________________________
Office Use:
Calculated Consumption
*Per Billing Software
Adjusted Consumption
*Update month/year used
December:
December:
January:
January:
February:
February:
Calculated Average:
Updated Total:
Calculated Charge:
Adjustment Charge:
Name:
Date:
Address:
Contact #:
Location of Leak: ___ Inside
___ Outside
Account #:
Date of Repair:
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