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Utility Billing Phone: [PHONE REDACTED] Utility Billing Fax: [PHONE REDACTED] Utility Billing Email: [EMAIL REDACTED] Today's Date: Home Phone: Account Number: Work Phone: Other Phone: Service Address: Approximate date leak appeared: Date leak repair was completed: Type of documentation for repair: Invoice: Receipt: Where on your property was the leak located: Description of the leak and repair: CITY OF MARYSVILLE UTILITY BILLING 501 DELTA AVE MARYSVILLE WA 98270 LEAK ADJUSTMENT REQUEST FORM Leak must be repaired and documentation of the repair must be provided before the adjustment will be considered. Name: By signing this form, I acknowledge that I have read the City of Marysville Leak Adjustment Policy. Once the City receives this form and the information is reviewed, we will verify the leak is fixed. After verification of the leak repair, an adjustment will be made and you will be notified. Leak adjustments are available once Customer Signature: