I understand that completion of this form does not guarantee a water/sewer adjustment will be given. I
also understand that all documents, including repair receipts, must be received before my account will be
reviewed for a leak adjustment. I also certify that all of the information submitted is true and correct and
applies to the account for which the credit is sought.
Phone
LEAK ADJUSTMENT REQUEST FORM
City
Please provide a detailed description of the leak and actions that were taken to complete the repairs:
Other (Please describe below) Toilet IrrigationUnderground Pipe
Account Number
FULTON COUNTY FINANCE DEPARTMENT
WATER & SEWER BILLING AND COLLECTIONS DIVISION
141 Pryor St, Suite 7001, Atlanta, GA 30303
Phone: (404) 612-6830 Fax: (404) 612-0333
Email: Adjustment.Request@fultoncountyga.gov
Signature
Date
LAST Name, First Name, Middle Initial OR Business Name
Street Address
Service Address
Customer Number
Email Address
Customer Name
Date Leak Repaired
Date Leak Occured
Leak Type
State
Zip Code
• This form, along with the appropriate repair statement, must be submitted for an adjustment to be considered. A
copy of a plumber or contractors repair bill must accompany this request for adjustment.
• If you repaired the leak yourself, a copy of the materials purchase receipt must accompany the request.
• Please note that the form is not a guarantee that a credit will be applied to your bill. If a credit is issued, it will be
reflected on your next bill. In most cases, an adjustment credit will only reduce and not eliminate an entire bill. You
will be responsible for any remaining amounts.
• You will be notified if the request cannot be granted or if additional information is needed.
mm/dd/yyyy mm/dd/yyyy
mm/dd/yyyy
Alternatively, this request along with the
required documentation can be submitted via:
• Fax (404) 612-0333; or
• In Person at:
o 11575 Maxwell Rd, Alpharetta, GA 30009; or
o 141 Pryor St SW, 7th Floor, Atlanta, GA 30303.
• If you are using Internet Explorer, you can use the button
below to email your request directly from this page;
• If you are using Chrome, Firefox or Safari, you will need to:
o SAVE this file on your computer;
o Open it with Adobe Reader;
o Use the button below to email the request.
OR
