Leak Adjustment Form PDF Details

Did you know that the City of Portland offers a Leak Adjustment Form? The form can be used to request a lower water bill if your property has experienced a leak. To qualify for the adjustment, you must provide documentation that shows the leak occurred on your property. You can find more information about the form and how to submit it on the City of Portland website.

This basic report will allow you to establish the time it'll take you to complete leak adjustment form, how many pages it's got, and some additional unique specifics of the form.

QuestionAnswer
Form NameLeak Adjustment Form
Form Length1 pages
Fillable?Yes
Fillable fields13
Avg. time to fill out2 min 51 sec
Other namescity of houston water leak, texas leak adjustment form, city of houston water leak forms, city of houston water bill adjustment form

Form Preview Example

CITY OF HOUSTON

Public Works and Engineering

Department

Leak Adjustment Request Form

Account No. _____________________________________

Utility Customer Service P.O. Box 4863

Houston, Texas 77210-4863 www.houstontx.gov

Service Address __________________________________

Daytime Phone No. __________________________

A City of Houston ordinance allows for a Leak Adjustment credit because of loss of water through an “excusable defect” in the customer’s water line. An excusable defect is due to a rupture or leakage caused by weather, settlement, corrosion, wear, or accident. Visible leaks such as faucet and hose leaks are ineligible. Credit may be given for one-half of the rate charged to usage in excess of the average. This adjustment is limited to a maximum of three (3) consecutive months and must be requested within six (6) months of the repair. Customers may apply for no more than two (2) leak adjustments in any twelve (12) month period.

I, _____________________________________, am the Responsible Party for the account at the above service address.

(Give full legal name and/or business identity)

I am asking the City of Houston to reduce the water bills for this account, to the extent allowed by city ordinance because of a leak beginning on (date) ______________ and repaired on (date) _______________. During this period, the following

additional water appliances (washer, dishwasher, spa, etc.) were installed at the service address. State “NONE” if none were added: ______________________________________. The water lost from this leak was not used by anyone.

IN ORDER TO PROCESS YOUR APPLICATION QUICKLY & EFFICIENTLY, PLEASE READ THE FOLLOWING CAREFULLY AND GIVE A COMPLETE AND CLEAR DESCRIPTION OF THE REPAIRS.

Type of leak on customer’s side of meter: _______________________________________________________________

Description of repair:________________________________________________________________________________

________________________________________________________________________________________________

Attach documentation of the repair date, address, type of repair, and cost. Acceptable documents include plumber’s statement/bill or a receipt for parts. Businesses with in-house maintenance may submit a statement signed by two (2) employees who witnessed the repair.

In all cases the City retains the right to make field verifications before approving leak adjustments. You will be notified by mail generally within 90 days whether your request is approved or denied.

I am familiar with all of the facts stated in this document and they are true and correct. Making false statements on this government record is subject to criminal prosecution under Chapter 37 of the Texas Penal Code. I certify that this application and attached documents contain no false statements.

Print Name: _____________________________________________________ Date: _______________________

Signature of person requesting a leak adjustment: _______________________________________________________

Complete the form and return to Utility Customer Service, Accounting Section, P.O. Box 4863, Houston, Texas 77210-4863. Please call our Customer Service Center at 713-371-1400, if you have any questions.

Leak Adjustment Req Form ENG - 2-09-10.DOC

How to Edit Leak Adjustment Form Online for Free

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example of empty fields in if i want an leak adjustment from the water

Note the demanded data in Leak, Adjustment, Re, q, For, mENG, DOC box.

Filling out if i want an leak adjustment from the water step 2

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