Water Leak Repair Verification NAME AS IT APPEARS ON BILL * First Name Last Name Email * SERVICE ADDRESS Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### ACCOUNT NUMBER * DO YOU RENT THE PROPERTY AT THIS ADDRESS? ONLY THE OWNER OR MANAGER MUST COMPLETE REMAINDER OF FORM IF RENT. * YES NO PROPERTY OWNER NAME First Name Last Name PROPERTY OWNER PHONE NUMBER (###) ### #### LEAK WAS REPAIRED BY: DESCRIBE THE LEAK, THE LOCATION OF THE LEAK, AND THE ACTION TAKEN TO REPAIR THE LEAK. APPLYING FOR A LEAK ADJUSTMENT DOES NOT PREVENT YOUR SERVICES FROM BEING DISCONNECTED OR LATE FEES. You are still responsible for paying your bill as normal. You will be contacted by the office once the adjustment is complete. I have read and agree to the above statement. I have read and do not agree to the above statement. I will email a receipt for the repairs to depclerk@coldwaterms.net. (The receipt must show the leak was outside.) I have read and agree with the above statement. I have read and do not agree with the above statement. I understand that the leak adjustment must be approved by a supervisor. If it is approved by a supervisor, I will be responsible for the balance. I have read and agree with the above statement. I have read and do not agree with the above statement. I understand that I am only eligible for one leak adjustment per 12 months. THERE ARE NOT EXCEPTIONS TO THIS POLICY. I have read and agree to the above statement. I have read and do not agree to the above statement. Thank you!