2. 

3. 
   

   
   

   Adjustment Request

   
   WATER LEAK

4. City of Tarpon Springs

   Utility Billing Division
   PO Box 5004
   Tarpon Springs, FL 34688-5004
   Phone: (727) 942-5609  Email: ubcts@ctsfl.us

6. I am requesting an adjustment on the utility bill at the following location:

8. Customer Name*
9. Email Address*
11. Address*
12. City*
13. State*
14. Zip Code*
16. Phone Number*
17. Date of Request*
    Date of Request
18. Account Number*

20. I am applying for a possible credit adjustment on my utility account with the understanding that once the review process has been completed, the account may not be eligible for a credit. The review process is performed in the order the requests are received and credits issued will be reflected on my utility statement as an adjusted amount. There will not be an adjusted bill sent out.

22. I understand that payment may not be withheld; the payment must be current to avoid the 10% penalty and possible termination of services.

24. Proof of Repairs

26. Upload Document

    Attach a copy of the plumber's repair bill.

27. Date on Repair Bill:
    Date on Repair Bill:
28. Date of Completion:
    Date of Completion:
30. What was repaired?
32. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
34. Electronic Signature*

    *By your signature, you are stating that you understand the terms of this request*

36. *In the event your account qualifies for an adjustment, the credit will be issued through the date of the repair, provided by the customer. Applying for an adjustment on a past due account does not exempt a customer from making payment. You must keep your account in good standing in order to avoid possible termination services.*

Leave This Blank:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit

* indicates a required field