Request for
Leak Adjustment
Date: _____________ Account #: ___________________ Outstanding Balance: ___________________
Name: _____________________________ Service Address: ___________________________________
Billing Address, if different: ______________________________________________________________
Home Phone: _________________ Work Phone: _________________ Cell Phone: _________________
Describe where the leak was located: ______________________________________________________
Describe the repair: ____________________________________________________________________
Attach a copy of your receipt.
Customer states that water service was received at the address described above and that increased usage
occurred due to a water leak in the plumbing, connections, and/or other property belonging to the customer.
Customer certifies that a licensed plumber or other professional was hired to repair the leak or they repaired the
leak themselves and that the job has been completed. Customer requests an adjustment to their water and sewer
bill for the month in which the leak occurred. A copy of the receipt is attached.
1. No adjustment to your account will be made until the billing cycle following the repair date is completed
and your water consumption has returned to normal.
2. This form must be completed and submitted to the City of Piedmont Utility Billing Department as soon as
possible and no later than 90 days from the date the leak occurred. Actual repairs are necessary; the
problem area should not simply be turned off.
3. Leak adjustments will be applied to the highest bill received during the time the leak occurred. Only two
monthly bill adjustments are allowed per calendar year with a maximum of a 30,000 gallon credit per
month.
4. The customer should keep their monthly bills current until the adjustment is made. If necessary,
customers may contact Utility Billing for a payment arrangement.
5. The customer will be notified when the adjustment is made. At that time, any outstanding account
balance will be due. If the adjustment results in a credit balance, future bills will be subtracted from the
credit balance. No refund checks will be issued.
6. Sewer is based on water consumption for the months of October, November, and December. If the leak
occurred during this time, the sewer service billing will be adjusted the following February based on your
prior year’s average.
City Manager’s approval is required for adjustment requests that are due to unusual or bizarre circumstances not
covered under this policy.
I have read and fully understand the terms of this agreement and certify that a leak in my plumbing
occurred and that it has been repaired.
Utility Billing Coordinator’s Signature
Date
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signature
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