2. Customer Information
4. First Name*
5. Last Name*
7. Phone Number*
8. Email*
10. Account Number*
    (12-digit)
14. Mailing Address of the Requester
16. Mailing Address*
18. City*
19. State*
20. Zip Code*
24. Service Address of the Property
26. Service Address*
28. City*
29. State*
30. Zip Code*
32. As the customer for the referenced Account and Location, I hereby request a “Courtesy Credit Adjustment for Excessive Consumption”, FKAA Policy 48-105.009, which occurred at this property during the billing period of:*
    As the customer for the referenced Account and Location, I hereby request a “Courtesy Credit Adjustment for Excessive Consumption”, FKAA Policy 48-105.009, which occurred at this property during the billing period of: Start Date

    —

    As the customer for the referenced Account and Location, I hereby request a “Courtesy Credit Adjustment for Excessive Consumption”, FKAA Policy 48-105.009, which occurred at this property during the billing period of: End Date
34. Upload Supporting Documentation*
36. Acknowledge & Sign
    The excessive consumption occurred within the past 90 days.
38. The excessive consumption was due to a leak which was underground, within a foundation or inside a wall and was not cause by negligence.
40. The request must be in writing (via this form) or by email which includes these acknowledgments.
42. I am providing a plumbers bill or receipts for parts to evidence that the leak was repaired.
44. I will be responsible for payment of two times my consumption for the same period of the prior years and the Leak Adjustment will be calculated on the remaining balance.
46. If consumption history is unavailable, the FKAA will use 5,300 gallons as a monthly average for a residential user. For all other Users, the FKAA will use an average derived from similar Users in its Service Area.
48. I understand and agree to the terms and conditions stated above.*

    1. Yes
50. Full Name*
51. Date*
    Date
Leave This Blank:


53. 1. Receive an email copy of this form.
54. Email address

    This field is not part of the form submission.

55. Submit

* indicates a required field