104 North Riverside Drive
P.O. Box 100
Edgewater, Florida 32132
Phone: (386) 424-2400 FAX: (386) 424-2409
(Please allow one (1) full bill cycle for credit to be issued)
Customer Name: Account Number:
Street Address: Phone Number:
This form is to be used for adjustments only. We will issue credit only for pool fills (new construction or complete
drain and refill for repairs). We do not issue credit for topping off pools, pressure washing, potable water usage for
irrigation, waterbeds, outdoor fun equipment or spas. The sewer portion will be credited on the amount of water
consumed for the fill. The owner is responsible for the water portion.
For leaks in plumbing lines, the adjustment will be the discretionary rate on water over the average. Sewer will be
credited to the average. Toilet flapper will be the discretionary rate on water and no credit for sewer since the
water went down the sewer.
Before we issue any credit on leaks, your consumption has to be two (2) times your average, ex: if your average is
5000 gallons a month, your consumption would have to be over 10000 gallons before we would issue credit.
It is still the customer’s responsibility to have their bill paid by the due date.
***Note: When leak continues for three (3) or more months, there will be no adjustment for the third or
subsequent months.
Purpose for Request: Pool Fill
Date Filled Gallons Used
Purpose for Request: Leak at Property High Use- Cause Unknown
Where was the leak located?
Did the water go down the sewer? Yes No
When was the leak repaired?
Please fill the form out, sign and date it, attach all repair receipts and return to the Utility Billing Department.
I certify that the above information is true and accurate to the best of my knowledge
Signature: Date:
Revised 05/04/2018
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