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WATER LEAK ADJUSTMENT REQUEST FORM Request Date: Account Number/CID: Customer’s Name as listed on Account: Mailing Address: Service Address (if different from mailing address): Date of Bill containing water volumes associated with the leak: Leak Repair Date: ♦ What was the source of the leak? ♦ Describe what was done to fix or correct the water leak problem(s). Proof of repair is requested and should be submitted with this form (i.e. plumber itemized invoice, repair parts itemized receipt, pictures or other documentation supporting any repairs).. The Utility may, in its sole discretion, grant a credit to a customer’s water bill for a leak in the customer’s water system under the following conditions: • The leak has been repaired. Proof of repair to the Utilities satisfaction will be required before a credit is granted. Proof of repair, i.e. receipts for any parts or services purchased, and any substantiating documents must be submitted with this form. • The customer is not in violation of any Utility policies and is otherwise current in the customer’s obligations to the Utility. • Once a customer receives a credit, the customer may not be granted another credit for two years, nor more than twice in the lifetime of the account for underground leaks, nor more than once for maintenance leaks. • In no case shall the amount of any credit exceed $500 for an irrigation system leak and $1,500 for any other type of leak. • By signing this request, I certify that I understand the terms and conditions of the Utilities leak adjustment policy and acknowledge that I may not be eligible for an additional leak adjustment in the future. • In all cases, the Utility Department retains the right to make field verifications before approving leak adjustments. You will be notified when your request is approved or denied. As the Customer for the above listed service address, I hereby apply for a billing adjustment under Ogden City Utilities’ Water Leak Adjustment Program. I confirm that the above and any attached information is true and accurate. Customer’s Name: (Please Print) Signature Date