Adjustment Request

Adjustment Request

Adjustment Request Customers may request a water leak adjustment after repairing a qualifying leak. Please complete the form below and upload any supporting documentation. Requests are reviewed in accordance with the City of Fort Walton Beach's Utility Billing Adjustment Policy. Please note: Requests must be submitted within 90 days of the repair date. Leak adjustments are limited to two (2) per account in a rolling 12-month period. Completion of this form does not guarantee approval. Account Number Request Date First Name* Last Name* Business Name Service Address* Phone Number* Email Address Date leak was discovered Date leak was repaired* Where was the leak located?* Brief description of the leak and repair* Supporting Documentation Invoice, receipts, etc. Email * Customer Certification I certify that the information provided is true and correct. I understand that submitting this request does not guarantee approval. Adjustment requests may take up to six (6) weeks to process. If approved, this request will count as one (1) of the two (2) allowable adjustments during a rolling 12-month period. I understand that I am responsible for paying my utility bill by the due date and that submitting an adjustment request does not extend the payment due date or prevent late fees, penalties, or service disconnection if my account becomes delinquent. If my request is approved, any applicable adjustment will be applied to my utility account after the review is complete. Acknowledgement* I have read and agree to the Customer Certification above. Signature* Submission Date* Leave This Blank: Receive an email copy of this form. Email address This field is not part of the form submission. Submit Submit and Print