Date repairs were made: _________________________
Were repairs made within 15 days of leak discovery or receipt of bill?
Yes No
A copy of the repair bill or receipt is required.
Please attach documentation to verify the existence, size and location of the leak repaired. Requests
without proper documentation will not be considered.
List the documents attached below:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Adjustment Process
Each request is reviewed and processed according to Town policy. The finance department will not process any requests
without a completed form and supporting documentation. Customers will be notified of the status of their request within
two weeks of being submitted.
Policy Summary
As a courtesy, the Town offers adjustment for unusual usage due to leaks that have been repaired in a timely manner.
Requests must be made within 30 days of billing date.
Requests are limited to once every three (3) year period. The number of billing periods eligible for adjustment is limited
to a maximum of two (2) consecutive periods. Adjustments will be made based on the customers “normal usage” which
is calculated as the average number of gallons used during the previous six (6) billing periods. If the customer does not
have at least six (6) previous bills, then the adjustment will be based on available data.
It is the customer’s responsibility to maintain proper work order of mechanical fixtures such as toilets, faucet,
connections or appliances. However, the customer may be eligible for a rate adjustment whereby the customer will be
charged at their highest normal rate tier for all usage above their historic usage.
If the leak exceeded 150% of historic usage, the customer may be eligible for a water and sewer leak adjustment. These
adjustments are calculated by crediting 50% of the water and sewer charges in excess 150 % of the customer’s normal
usage.
If the customer can prove the water leak did not enter the sewer system, they may receive a sewer adjustment. This
adjustment is calculated by crediting 100% of the sewer charge in excess of the customer’s normal usage.
By signing this form I swear that the repairs reported were made, I have read and reviewed the Town’s entire leak policy
and I hereby declare the statements and documentation to be accurate and true to the best of my knowledge.
______________________ ______________________________________________________
Date Signature
