Leak Adjustment Application - COPY

Para obtener un formulario en español, haga clic aquí.

Name*

First Name

Last Name

Service Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Account Number*

Daytime Phone Number*

xxx-xxx-xxxx

Email*

Leak Detected On*

Leak Repaired On*

Please provide a brief explanation of the leak and associated repairs below:*

Service*

Water Irrigation

Self repair

By checking this box you are certifying you do not have an invoice or receipt from a licensed plumber

Upload proof that the leak has been repaired by either a receipt for supplies purchased or an invoice from a licensed plumber.*

No File Chosen

File uploads may not work on some mobile devices.

Upload proof that the leak has been repaired by a receipt for supplies purchased*

No File Chosen

File uploads may not work on some mobile devices.

By signing below, you certify that you are the responsible party for the account at the above service address. You further certify that you are requesting a leak adjustment from the Coweta County Water & Sewerage Authority and acknowledge that the "Leak Detected On" and "Leak Repaired On" are accurate the best of your knowledge. Furthermore by submitting this application you understand that no leak adjustment will be issued without the submission of all appropriate documentation and that the Authority will provide an adjustment at its sole discretion.

Signature*

[clear]

Use your mouse or finger to draw your signature above

Today's Date*