WRC Water Loss Adjustment Request Form

Page 1

Requestors Information

First Name

Last Name

Street Address

Building Number

City

State

Zip Code

Email Address

Phone Number

ext.

Billing Account Number

Property Information

Street Address of Property

Apartment or Building Number

City

State

Zip Code

Page 2

Reason for Billing Adjustment Request (Choose one)

Leak – A water loss occurred due to a leak; the cause of the leak was identified and subsequently repaired. Unexplained Increase in Water Usage – An unexplained increase in water usage occurred during a billing cycle that subsequently returned to normal usage in a later billing period. The unexplained increase exceeded two times the normal usage when compared to usage during similar billing periods (i.e. summer months).

Choose one reason

About the leak

What date was leak was discovered?

What date was the leak repaired?

Please provide any documentation related to the leak repairs.

About the unexplained increase

What is the date of water bill showing increased water usage?

Has there been a change or transfer of ownership of the property from the date of the leak or unexplained increase in water usage to the date of the billing adjustment request?

YesNo

Additional Information (This can be for staff notes, or customers to share any additional information about the leak/adjustment request).