Electronic Billing Appeal Form

Use this form to submit your information electronically. Fill out the fields and click the SUBMIT button at the end.

By completing the form you CERTIFY:

• that I have read the District Policies and this Appeal conforms to them.

• that the contents of this Request are true and correct.

• that the customer has complied with all requirements for relief under those Policies; and

• that the attached are true and correct copies of the invoice(s) paid for repairs.

Today's Date (required)

Account Number (required)

Name on Account (required)

Property Account Address (required)

Contact Person Name - if different than above

Contact Person Address - if different than above

Contact Person Phone (required)

Contact Person Email (required)

Where was leak / loss - Select one

Dwelling

Separate Irrigation System

Both

Date Leak Discovered / Loss Noticed

Date Leak / Loss Repair

Describe the water loss

Describe the repairs to your system

Name of person or entity discovering leak / loss

Name of person of entity repairing leak / loss

Basis of appeal - Select as many as approriate (required)

Water District Water Leak Policy #23-09 WD

Sanitary District Water Leak Policy #24-07 WD

Water District Extraordinary Water Usage Appeal Policy #2024-1017 WD

Other

Amount being appealed to Water: $

Date(s) of charges for Water (required)

Amount being appealed to Sanitary: $

Date(s) of Charges for Sanitary

Comment - further explanation

Supporting Documentation

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