Water Leak Adjustment Request

Customer's Name as listed on Account:

Account Number:

Service Address:

Address Line 1

Address Line 2

City

State

Telephone Number:

Date(s) of Bill(s) containing water volumes associated with the leak:

Leak Repair Date:

The Water Leak Adjustment Request Form and documentation of repairs must be received within sixty (60) days of the due date listed on the Customer’s utility bill for the period in which the leak occurred.

What was the source of the leak?

Describe what was done to fix or correct the water leak problem(s). Proof of repair is required and must be submitted with this form (i.e. plumber itemized invoice, repair parts itemized receipt, or other documentation supporting any repairs).

Proof of Repair

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Has a water leak adjustment been requested or made for this service address during the last year?

Yes
No

If Yes, when?

If residential, how many people reside at the service address?

Was the premises vacant or unoccupied when leak occurred?

Yes
No

If yes, please provide the period of time of the vacancy:

Customer's Name:

Date:

Forms

The Water Leak Adjustment Request Form and documentation of repairs must be received within sixty (60) days of the due date listed on the Customer’s utility bill for the period in which the leak occurred.

Rules governing the CTUB Water Leak Adjustment Program are located at www.ctubwv.com and www.psc.state.wv.us.