P.O. Box 608, 3303 Hwy 31-W

White House, TN� 37188

615-672-4110

Leak Adjustment Request

To qualify for a leak adjustment, the leak bill(s) must exceed the average usage by 100% or greater.

One leak adjustment is allowed per calendar year for documented repaired leaks. A maximum of three

months usage may be adjusted.

Documentation of leak repair is required to be submitted with the leak form in order to

receive an adjustment (receipt of products purchased or receipt from plumber).

Sewer will be adjusted for outside leaks.� Inside leaks will not be subject to an adjustment for sewer charges.

Once the usage returns to normal, any adjustments will be reflected on your bill.

To determine the adjustment, we will subtract 50% of the excessive usage (the amount above the average bill)

and any penalties related to the leak bill(s).

NOTE: If your account has a past due balance, your account will be subject to disconnection unless

this letter and documentation of repair is received in our office prior to your

disconnection date.

Name on bill

I am requesting a leak adjustment for my water bill at

Phone Number

Date leak found

Date leak repaired

Brief explanation of leak:

_______________________________

Account Number��Sign Above If You Are Mailing In This Form ��Date

By checking this box, I am stating that the above information
is accurate to the best of my knowledge.