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**REQUEST MUST BE AT LEAST 24 HOURS PRIOR TO POOL FILL**
Submittal of this form is NOT a guarantee that credit will be applied to your utility bill. You will be notified by phone or email if the request is approved, denied or additional information is needed. It is a request form only, and each customer will be allowed only one pool credit per calendar year. Customers account must be paid up to date. It is the customer’s responsibility to pay their bill in full by the due date while the adjustment request is being reviewed and processed. Failure to pay your utility bill may result in late fees or your water being turned off and your adjustment being reversed if approved.
To determine if your charges may be adjusted, complete the form below and attach the following documents and follow all policy guidelines.
Only the account holder or authorized user can make a request for adjustment.
Only Account Holder or Authorized User can make requests for adjustments.
Beginning Read: _______________Date: ________________ Ending Read: ___________________ Date: _____________
Total Gallons Used: __________________________________ Approved or Denied: ______________________________
Amount Adjusted: ___________________________________
Customer Service Representative Date
This field is not part of the form submission.
* indicates a required field