Midlothian, TX · Ellis County
Leak Adjustment Request Form
Water and sewer account customers use this form to request an adjustment after repairing a leak at their service address.
What this form is
The form requests a leak adjustment and asks for the customer’s account name, service address, contact details, a description of the leak, and the repair date. Attach a plumber’s statement and/or receipts. The form says there must be at least six months of usage history, requests must be submitted within 90 days of repair, and review may take up to two billing cycles.
Who needs it
A water or sewer account customer seeking an adjustment after a leak repair should complete this form and attach the requested supporting documentation.
How to submit it
The form lists walk-in, mail, night box, email, and fax as submission options. Email [email protected] or fax 972-775-7160; no mailing address is provided.
About notarization
This form is signed and dated without a notary; attach a plumber’s statement and/or receipts, with no sworn or notarized attachment identified.
How to submit this form
- 1
Download The Form
Download the Leak Adjustment Request Form PDF.
- 2
Complete The Form
Enter the account customer name, service address, contact details, leak description, repair date, and customer signature.
- 3
Gather Attachments
Attach a plumber’s statement and/or receipts.
- 4
Submit To The City
Submit by walk-in, mail, night box, email, or fax. The form lists [email protected] and fax 972-775-7160.
Frequently asked questions
- Do I need a notary for the Leak Adjustment Request Form?
- No. The form has a customer signature and date line but no notary block. Attach a plumber’s statement and/or receipts; the form does not identify these attachments as sworn or notarized.
- How do I submit the Leak Adjustment Request Form?
- The form lists walk-in, mail, night box, email, and fax as options. It provides [email protected] and fax number 972-775-7160; it does not give a mailing address.
- What do I need to attach?
- The form requires a plumber’s statement and/or receipts to be attached. It also asks for a brief description of the leak and the date it was repaired.
- When must I submit a leak adjustment request?
- The form says requests must be submitted within 90 days of the repair and that at least six months of usage history is required. Review may take up to two billing cycles.
Need something notarized?
This Leak Adjustment Request Form doesn’t need a notary — but Texas residents can notarize other documents online with a commissioned online notary.