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 - 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

Name of person of entity repairing leak

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

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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Arch Cape Water & Sanitary Districts (the "District") is committed to ensuring that its services are accessible to all members of the public. As part of this commitment, the District strives to provide an accessible website compatible with the Web Content Accessibility Guidelines (WCAG) version 2.1, AA, and commercial screen reading software. Features of the website are created to allow individuals with vision and other impairments to understand and use the website to the same degree as someone without disabilities.

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Contact our compliance support team via telephone at: (888) 765-1970

Ongoing Compliance Information

Compliance Coordinator

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Compliance Procedures

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Report a Website Accessibility Issue

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