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2. Utility Adjustment Request Form
4. Must be completed by the account holder
6. Customers of the City of Casselberry may request an adjustment on the current water bill if they have recently encountered a leak, pool fill, or unexplained/unintended usage by completing and submitting this application.

   As a customer of City of Casselberry Utilities Division, a customer may request an adjustment to the current water bill if they have recently encountered double the usage of consumption due to a leak, pool fill or new sod in a 12-month period or unexplained/unintended usage once in a 3-year period. The adjustment request must be submitted within 90 days from the bill date including valid proof of repair and 30 days from bill date for unexplained/unintended use. The submittal of this request does not prevent the account from collection activity, including service interruption. Please refer to the adjustment ordinance 18-1499 and/or adjustment policy for full details.

   Please contact Utility Customer Service at (407) 262-7760 for further details.

9. VALID PROOF OF REPAIR MUST BE SUBMITTED BELOW
11. Customer Name*
12. Account Number
14. Service Address*
16. Suite or Apartment Number
18. City*
19. State*
20. Zip*
22. Phone Type*
    -- Select One --CellularHomeWork

    Press the down arrow key to access the values available for this field or start typing to filter the values
23. Telephone Number*
24. Email Address
    Under Florida law, e-mail addresses are public records.
26. Please select reason for the adjustment request*

    1. Pool Fill
    2. Pool Repair
    3. New Sod
    4. Leak
    5. Unexplained or unintended usage
28. Date of pool fill or repair
    Date of pool fill or repair
29. Date of Sod Installation
    Date of Sod Installation
30. Date Leak Repaired
    Date Leak Repaired
32. Please give brief description of what occurred*
34. Please attach proof that repairs were made*
    Invoice, Receipt, Pictures, etc.
39. Please allow 10 business days for processing
41. Acknowledgement

    By submitting this application, I have read and understand the adjustment policy. (I also understand my responsibility of any balance on the account after the adjustment has been applied must be paid or my account will be subject to interruption of service and/or report to the collection agency.)

    I certify that the above information is true to the best of my knowledge.

43. Signature
45. Signature
46. Date
    Date
48. Submit
    Completed forms may be printed and mailed to P.O. Box 180819, Casselberry, FL 32718-0819 or delivered in person at 95 Triplet Lake Drive, Casselberry, FL 32707
50. Email Notice

    Under Florida law, e-mail addresses are public records. If you do not want your e-mail address released in response to a public-records request, do not send electronic mail to this entity. Instead, contact this office by phone or in writing.

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52. Submit

* indicates a required field