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2. Water Leak Policy Request Form
   I am requesting to use my privileges as a Pilot Point resident to use my (1) one time use of the water leak policy at this time. I understand that the policy states that this can only be used one time in a three year period.
4. Water Leak Policy
   Please Click Here to read the Water Leak Policy
6. Signature*
   I have read and understand the Water Leak Policy.
7. Date
   Date
9. Service Address*
10. Utility Account Number
12. Name*
13. Email Address*
15. Mailing Address*
17. City*
18. State*
19. Zip Code*
21. Phone Number*
22. Fax Number
24. Billing Date*
    Billing Date

    Billing Date
25. Consumption Period Covered
27. Describe the reasons for the requested adjustment. *
    Email receipts, pictures, and supporting documents to ub@cityofpilotpoint.org
29. Administration Use Only
    Water Adjustment $________________________
30. Administration Use Only
    Sewer Adjustment $________________________
Leave This Blank:


32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit Submit and Print

* indicates a required field