Fillable Utility Adjustment Request (Bal Harbour Village)

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Utility Adjustment Request (Bal Harbour Village)

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The Utility Adjustment Request (Bal Harbour Village) form is 1 page long and contains:

  • 2 signatures
  • 2 check-boxes
  • 20 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Bal Harbour Village

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Bal Harbour Village Hall ● 655 96
th
Street, Bal Harbour ● FL 33154 ● 305-866-4633 ● Fax 305-868-6575
Utility Adjustment Request
Customer Information
Name on Account
Account Number
Service Address
Email Address
Contact Number
Repair Information
Name of Plumber ___________________________________________________________
Plumbers License Number ___________________________________________________________
Date of Repair ___________________________________________________________
Description of Leak ___________________________________________________________
___________________________________________________________
Description of Repair ___________________________________________________________
___________________________________________________________
Requirements
• Attach copies of repair bill(s) and/or a letter from the company or person(s) completing the repairs.
• Account must be current
• Billing month in which the leak occurred must amount to a 40% increase in regular consumption.
• Return form to Bal Harbour Village Hall or send via email to water@balharbourfl.gov
I understand I can be considered for a Utility Adjustment if all leakage has been corrected,
consumption has decreased and all requirements listed have been met.
_________________________ _____________________________________
Date Customer Signature
INTERNAL USE ONLY
Customer Average (Gallons) __________________ Leak Amount (Gallons) _________________________
☐ Approved by _____________________________________________________________________
☐ Not Approved ____________________________________________________________________
Adjustment Amount (Gallons) _________________ Adjustment Amount (Dollars) ____________________
_____________________________________________ ______________________________
Authorizing Signature Date
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Utility Adjustment Request (Bal Harbour Village)

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Completed 14 January 2021

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