2. Leak Adjustment Policy
   
4. Today's Date*
   Today's Date
5. Last 4 Digits of Account Holder*
   Only Account Holders are allowed to make changes or request on any account.
6. Account Number*
   Please include entire 13 digit account number with dashes.
8. First Name of Account Holder*
9. Last Name of Account Holder*
11. Street Address of Account*
13. Email*
14. Phone Number*
    ex: 254-666-6171
16. Beginning Date Of Leak*
    Beginning Date Of Leak
    Please give the date that it was first known that the leak started.
17. Date of Repair*
    Date of Repair
    Please Give The Date That The Repairs Were Made.
19. Description of Leak*
    Please leave a brief description of the location and type of leak. In all cases the City retains the right to make field verifications before approving leak adjustments. You will be notified, generally within 10 days, whether your request is approved or denied.
21. Documentation of Repair*
    Upload Documentation of the Repair Date, Address, Type of Repair, And Cost. Acceptable Documents Include Plumber's Invoice or Receipt of Parts. Business or Landlords With Maintenance Staff May Submit A Statement Signed By The Business Management/Owner Of Repairs Made.
23. Policy & Terms*

    I am the Legal Account Holder of the above account. I am familiar with all of the facts stated in this document and they are true and correct. Making false statements on this government record is subject to criminal prosecution under Chapter 37 of the Texas Penal Code. I certify that this application and attached documents contain no false statements.

    1. I have read the Leak Adjustment Policy. I understand and agree to the Policy & Terms.
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25. 1. Receive an email copy of this form.
26. Email address

    This field is not part of the form submission.

27. Submit

* indicates a required field