S:\FORMS\Utility Billing\Request for Account Adjustment 8/21/2018
Instructions: 1. Complete this form in its entirety; sign form.
2. Submit application to City by one of the following methods:
a) In person: to 88184 8th Street, Veneta. c) Mail to: P.O. Box 458, Veneta OR 97487
b) Fax to: (541) 935-1838 Attn: Utility Billing
3. Provide at least one piece of government issued, photo-bearing identification.
on the
Date Leak Found
Requester's Signature:
day of the month to the City of Veneta, beginning
I/We agree to pay $
Service Address: Account#:
Type of Adjustment:
Circle one and provide the applicable information
Payment agreement statement (for significant leaks only.)
Alternate Phone#
Employers Name
Employers Phone#
** Attach copy of repair bill or receipts for necessary parts (for verification purposes only, no reimbursement should be expected)
By my signature below I/We verify that all the information provided on this form is true and accurate.
Request for
Account Adjustment
Mailing Address:
PO Box 458 * Veneta, OR 97487 * 541-935-2191 * Fax 541-935-1838 * www.venetaoregon.gov
I/We also understand the payments agreed to above are in addition to the payments required for my/our regular monthly utility bill.
Name on Account:
Date Leak Repaired **
Previously Provided Move Out Date
Correct Move Out Date
Primary Phone#
I/We understand the City will not provide reminders for the above specified payments and that failure to pay as indicated above
could lead to discontinuance of service without further notice.
20____ and each month thereafter until my/our account balance associated with the leak is paid in full.
Phone# (s):
Fill out adjustment paperwork at: S:\FINANCE DIRECTOR\WATER and SEWER\FORMS
Requester's Signature:
City Use Only
Description/Location of Leak
Leak Repaired By:
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