Fillable Residential Customer Water Leak Credit Application

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Residential Customer Water Leak Credit Application

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The Residential Customer Water Leak Credit Application form is 2 pages long and contains:

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Country of origin: CANADA
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Water and Waste Department • Service des eaux et des déchets
Water Leak Credit Application
Residential Customer
Please complete this form in full and return to us via email or mail. If it is not completed in full, we cannot
process your application.
Date: _____________________ Utility account number: __________________________________________
Customer information
Name (as i
t appears on bill): ______________________________________
Driver’s
licence number: ___________________________________
Daytime phone number
: ____________________ Email: __________________________________
Would you prefer we contact you by telephone
□ or email □?
Please provide names of any other adults responsible for this utility account:
Name: Driver’s licence number:
Water leak location information
Address of leak: __________________________________________________________
Number
of people (including chi
ldren) that reside at this address: ______________
Current meter reading: _____________________ Date of meter reading: _____________________
Claim information
Date of first high water use notification: ______________________ Repair date: ______________________
Describe the nature of the plumbing problem(s) and what was done to fix or correct it. Proof of repairs is required
and must be submitted with this application (e.g., plumber’s invoice with explanation of repair or receipts for parts
combined with photos of the repair).
Page 1
Will you or have you submitted a claim with your homeowners’ or tenants’ insurance company?
Yes
□ No □
If so, please provide copies of the insurance company’s response.
Will you be receiving any monetary assistance from any other third party for the high water use?
Yes
□ No □
Please list all sources and amounts:
Have you applied for a credit in the past under policies related to high water bills (e.g., this Policy, the Adjustment
Policy for High Bills for Water and Sewer Services, Financial Hardship Adjustments)?
Yes
□ No □
If so, when: ___________________________
Was the property vacant or unoccupied when the leak occurred? Yes
□ No □
If so, provide the period of time the property was vacant or unoccupied: _________________________________
As the customer for the above noted property, I hereby apply for a credit under the City of Winnipeg’s Water Leak Credit
Policy and request that the credit be applied to my utility account. I confirm that the above and attached information are true
and accurate. I have read the Water Leak Credit Policy and understand that if a credit is granted, it is on a one time only
basis for all adult residents (excluding adult children).
Print Name _____________________________ Signature ________________________________
Print Name _____________________________ Signature ________________________________
Print Name _____________________________ Signature
________________________________
PLEASE NOTE:
Completion of this application does not guarantee a credit will be applied to your utility bill. To avoid
additional service charges, you must pay the amount owing on your utility bill while the credit review process is underway.
Accounts are adjusted only once a water leak credit application is approved.
Send us the completed application and required documents as indicated above by:
Mail: Water Leak Credit, City of Winnipeg, Water and Waste Department
510 Main Street, Winnipeg, MB, R3B 3M1
Email:
WaterLeakCredit@winnipeg.ca
Questions?
Contact our Utility Billing Centre, by phone at 204-986-2455 or by email at utilitybill@winnipeg.ca
Privacy
Your personal information is being collected pursuant to s.36(1)(b) of The Freedom of Information and Protection of Privacy
Act. This information will be used so we can apply a credit for the water leak if your application is approved and for
communication and administration related to your utility service and will not be used or disclosed for any other purposes,
except as authorized by law. If you have any questions about the collection of this information, contact the Corporate Access
and Privacy Officer by mail to City Clerk’s Department, Susan A. Thompson Building, 510 Main Street, Winnipeg MB, R3B
1B9, or by telephone at 311.
Page 2
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Residential Customer Water Leak Credit Application

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Completed 8 January 2021

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