2. Leak Adjustment Request Form

   Applying for a leak adjustment does not guarantee an adjustment.  Each application goes through a Review Process that may take 30-60 days or longer.  Only one adjustment per 12-month period is allowed per account.

   Once your request is received, a Customer Service Representative will contact you with further information within 5 business days.

   If you have questions, please call the Waynesboro City Utilities Customer Service at 540-942-6643 Option 4.

4. Account Number - Customer ID Number*
5. Account Holder Name*

   Only the account holder can request an adjustment

7. Service Address # and Street*
8. Billing Address # and Street
10. City
11. State
12. Zip
14. Phone Number*
15. Email Address*
19. Date of Repair
    Date of Repair Start Date

    —

    Date of Repair End Date
20. Number of Occupants*
    -- Select One --Business - Undetermined0 - building was unoccupied/vacant123456+
22. Where was repair made:
    -- Select One --Repair on ToiletRepair on Service Line between House and MeterUnknown/No Repair MadeHose/Outside Faucet/Hydrant Left OnHot Water HeaterMultiple IssuesIndustrial MachineryOther
23. If Other, please describe briefly:
25. Receipt of Repair*

    If a licensed plumber made a repair, please provide a copy of the invoice.

    If In-House Maintenance made a repair, please provide a work order if no invoice is available.

    If a repair was made and no receipt is available, please provide a signed letter stating name of person who made repair, what was repaired, and the date of repair. 

    If no repair was made, please provide a signed letter stating any known information about the excess water usage, or stating lack of information thereof.  No repair being made may lead to denial of a leak adjustment.

27. Repairs Completed By:*
28. Description of Repair:*
30. Requesting an Estimated Payment

    If your current billing is higher than you are able to pay, please check the box below and we will provide you with a payment based on your estimated adjustment.  This amount is not your approved adjustment until you have been notified of such.  You may have a balance due or a credit on your account after the Review Process is complete.

    If you do not select this option, you are agreeing to pay the current billing in full.

    1. Yes, please provide and estimated payment while my account is in Review

34. INCOMPLETE LEAK REPORTS AND LEAK REPORTS SUBMITTED WITHOUT A RECEIPT FOR REPAIRS MAY NOT BE CONSIDERED FOR REVIEW. 

    If a second leak occurs after repairs are completed by a homeowner (rather than a licensed professional plumber), an additional leak credit may not be considered. A leak adjustment is allowed only once in a 12-month period and for only 2 consecutive bill cycles.

    The customer is responsible for prompt payment of all water and sewer services billed by the City of Waynesboro Utilities Department. The customer further understands that submission of this leak report is a request for consideration for a leak credit and does not relieve them of responsibility for payment for water and sewer charges.

36. NAME OF PERSON COMPLETING APPLICATION
    Please Note: Only the Account Holder and Authorized Users can make changes to the Utility Account
37. Date of Application
    Date of Application

39. If you haven’t received a water bill through the date your water leak was repaired we will process your claim after your next bill. It takes an average of 30-60 days to process customer Water Leak Adjustment Claims. Your patience during this time will be much appreciated. If you qualify, you will not receive any delinquency charges while we process your claim. However, you may still receive a notice as the system generates them automatically

Leave This Blank:


41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit Submit and Print

* indicates a required field