Leak Adjustment Application Form

The City of Hurst understands that some of our residential water utility customers may experience water loss from broken pipes, irrigation system malfunctions or damage, leaky and defective toilets and other unforeseen issues. Water loss of this nature can result in larger than normal water bills and we are prepared to help. The City of Hurst has a “Leak Adjustment” policy that allows us to apply credits to utility bills that experienced an increase due to a line break or other equipment failure. If you experienced damage that resulted in a higher than normal water bill here is what you should know.

Residential water utility customers may apply for a leak adjustment by filling out a Leak Adjustment Request Form. Leak adjustment requests must include receipts of the repairs (plumber bill or repair receipts.) Requests for a leak adjustment credit must be submitted within 90 days of the date on the initial bill reflecting the increased usage.

Once the leak adjustment is submitted, it will be reviewed by the Water Office Manager for compliance before approval. The residential customer is still responsible for the water bill during the approval process.

After the leak adjustment is reviewed, the residential customer will be contacted about the results. If a credit is given, it will be documented in our billing system and applied to the customer’s account.

Leak credits are based on water consumption, not dollar amounts.

Please complete all form information below to apply for a leak adjustment:

1

Customer Name

 *

Customer Name

First Name

Last Name

2

Please select the one that applies.

 *

Please select the one that applies.

I am the owner of this home.

I am the renter of this home.

3

Full Address

 *

Full Address

Street Number and Name	Unit Number
Postal/ZIP Code

4

Phone Number

 *

Phone Numberext.

5

Email

Email

6

Today's Date

 *

Today's Date

7

Date of Occurrence

 *

Date of Occurrence

8

Date of Repair

 *

Date of Repair

9

Work completed to resolve the leak. PLEASE BE DETAILED.

Work completed to resolve the leak. PLEASE BE DETAILED.

10

Please upload all receipts related to the repairs required by your description above:

 *

Please upload all receipts related to the repairs required by your description above:

Please upload all receipts related to the repairs required by your description above: Click button for uploading file Clear Maximum size allowed: 5 MB Allowed types: .gif, .jpg, .jpeg, .png, .doc, .docx, .xls, .xlsx, .rtf, .pdf, .txt

Please upload all receipts related to the repairs required by your description above: Click button for uploading file Clear Maximum size allowed: 5 MB Allowed types: .gif, .jpg, .jpeg, .png, .doc, .docx, .xls, .xlsx, .rtf, .pdf, .txt

Please upload all receipts related to the repairs required by your description above: Click button for uploading file Clear Maximum size allowed: 5 MB Allowed types: .gif, .jpg, .jpeg, .png, .doc, .docx, .xls, .xlsx, .rtf, .pdf, .txt

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

Page 1 / 1