Water/Wastewater Leak Adjustment Request Form
This form is not a guarantee that a credit will be applied to your utility bill. You will be notified by letter if the
request cannot be granted or if additional information is needed. By submitting this form and all required
documentation, customer certifies that all information is true and correct to the best of their knowledge.
Date: _______________________
Name on Utility account: ___________________________
Customer-Account numbers: ________________________
Service Address: ______________________________________________________________
Daytime Contact Phone No.: ________________________
Date Leak Occurred: _____________________ Date Leak Repaired: _____________________
Type of Leak:
____ Toilet ____ Dishwasher
____ Sink ____ Bathtub
____ Leak at Plumbers Connection ____ Main Service Line
____ Interior Water Line Problem (state location) ________________________
____ Other: ______________________________________________________
Required Documentation
Copy of repair invoice attached YES ______ NO _______
(if repaired professionally)
Copy of repair receipts attached YES ______ NO _______
(if repaired by owner/tenant or agent)
Brief description of leak and action taken to repair:
______________________________________________________________________________
Customer Signature: _____________________________________________________________
The leak adjustment form and all documentation can be submitted as follows:
o Mail to Leak Adjustments P.O. Box 608, Chesterfield, VA 23832
o
Fax to 804-717-6248, attn.: Leak Adjustments
o
Email to utilitybillservices@chesterfield.gov
______________________________________________________________________________________
County Office Use Only
Reread Date: __________________________ Service Order Number: _____________________
Average Consumption: __________________
Adjustment Completed by: _______________ Date Adjustment Completed: ________________
Approved: _______Yes ________No Date Letter Sent to Customer: _______________
click to sign
signature
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