Fillable LEAK PENALTY OTHER (City of Dahlonega)

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LEAK PENALTY OTHER (City of Dahlonega)

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LEAK PENALTY OTHER
DATE:____________________________________________________________________________
NAME ON ACCOUNT:_______________________________________________________________
ACCOUNT NUMBER:________________________________________________________________
SERVICE ADDRESS:________________________________________________________________
PHONE:___________________________________________________________________________
DATE OF REPAIR (IF LEAK ADJUSTMENT):_____________________________________________
*REPAIR DOCUMENTS MUST BE ATTACHED FOR VERIFICATION OF LEAK
EXPLANATION OF ADJUSTMENT:_____________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
PRINT NAME:______________________________________________________________________
SIGNATURE:_______________________________________________________________________
FOR OFFICE USE ONLY
APPROVED BY:
DATE APPROVED:
AMOUNT OF ADJUSTMENT:
CITY OF DAHLONEGA
465 Riley Road
Dahlonega, Georgia 30533
Phone: 706-864-6133 • Fax: 706-864-4837
REQUEST FOR ADJUSTMENT ON UTILITY ACCOUNT
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LEAK PENALTY OTHER (City of Dahlonega)

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Completed 22 January 2021

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