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3. 

5. As a customer of the City of Altamonte Springs, you may request an adjustment on your current water bill if you have recently encountered a leak, or pool fill, by completing and submitting this application. Valid proof of repair must be included (if applicable). Submittal of this request does not prevent your account from collection activity, including service interruption. A payment must be made on the account.

7. Account Number:*
8. Phone Number:*
10. Customer Name:*
12. Property Address:*

14. I, the account holder of the property located above, hereby request consideration of an adjustment to my account.

16. Reason for Adjustment:

    1. Pool Fill
    2. Leak
17. Proof of Repair:*

    (must be plumber's invoice or receipt)

18. Date of Leak Repair/Pool Fill:*
    Date of Leak Repair/Pool Fill:
20. Description of Occurrence:*
22. Terms and Conditions:

    By submitting this application, I am aware that an adjustment is not guaranteed. I also understand my responsibility of any balance on the account after the adjustment has been applied must be paid or my account will be subject to interruption of service and/or reporting to the collection agency.

24. Acknowledgement:*

    1. I certify that the above information is true to the best of my knowledge.
26. Signature:*
27. Date:
    Date:
Leave This Blank:


29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit

* indicates a required field