Fillable STATEMENT OF REPAIR Submit a copy of a (Pinellas County Government)

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STATEMENT OF REPAIR Submit a copy of a (Pinellas County Government)

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Revised 05/18
STATEMENT OF REPAIR
Submit a copy of a licensed plumber’s invoice or complete this form if your high bill is the result of a leak that has
been repaired. You may qualify for a leak adjustment if you have had a leak repaired and the consumption during
the billing period in which the leak was repaired or the prior billing period was at least two times or 20,000 gallons
over the average bimonthly bill.
Account Number: __________________________ Today’s Date: ____________________
Service Address: _____________________________________________________________________
What type of repair was made? (Be Specific)
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Date of repair? ___________________________ Who did the repair? __________________________
STATE OF FLORIDA
COUNTY OF _______________________
Sworn to (or affirmed) and subscribed before me this ___ day of ________, 20___, by
______________________________
(Printed name of person making statement)
______________________________
(Signature of person making statement)
_____________________________
(Signature of Notary Public- State of Florida)
_____________________________
(Name of Notary Typed, Printed or Stamped)
(NOTARY SEAL)
Personally Known ____ or Produced Identification ____
Type of Identification Produced___________________
Please submit documentation to ONLY ONE of the following:
Mail:
Pinellas County Utilities
Attention: Adjustments
P.O. Box 1780
Clearwater, FL 33757-1780
Email: utlleakrepairdocs@pinellascounty.org * Receive-only email box address.
General account questions & concerns can be sent to Customer Service via custsrv@pinellascounty.org .
You may also contact us by telephone at (727) 464-4000 Monday – Friday, 8:00 a.m. – 5:00 p.m.
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STATEMENT OF REPAIR Submit a copy of a (Pinellas County Government)

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Completed 30 July 2020

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