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2. City of The Colony Leak Adjustment Request
4. Date*
   Date
6. Name*
7. Email Address*
9. Address*
11. Phone Number*
13. Water Account Number*
15. Type/Location of Leak*
16. Date Range of Leak*
18. Plumber or Self Repair*

    1. Self Repair
    2. Plumber Repair
19. Name of Plumbing Company (if applicable)
21. Upload Repair Receipt*
23. City of The Colony Leak Adjustment Policy

    If eligible, the following criteria shall be used for assessing the value of the proposed leak adjustment: 

    1. Adjustment requests must be submitted no later than 90 calendar days from the billing date in question. 

    2. A leak adjustment is only given once per twelve- month period per account. 

    3. In order to be considered for a leak adjustment, consumption use must show over 15,000 gallons on the bill in question.  If leak adjustment is granted, usage over 15,000 gallons in that billing period will be reduced to the lowest rate tier.  The leak credit comes from the difference in the rate tiers.  

    4. Evidence of professional repair must be in the form of an invoice provided by the customer, which should include the company name, address and phone number. If self-repaired, a written statement along with receipts for parts purchased to perform the repair must be provided. 

25. Acknowledgment

    By signing, I hereby do affirm that the above statements are true and correct. If any information is found to be false and/or misleading, the leak adjustment may be denied and/or any credit adjustment posted to my account, as a result of approval of this request, may be forfeited. Processing may take a week to be resolved during which time the account must remain in good standing with any/all outstanding balances paid in full (including penalties) by their respective due dates. If your account(s) is not in good standing, your request will be subject to immediate denial. 

27. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your request will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
29. Electronic Signature*
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31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit

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