Customer Adjustment Request Form

Customer Adjustment Request Form

Hernando County Utilities Department
***Please Read***

***Please note, it is the customers responsibility to turn off autopay during the adjustment review process to avoid the total account balance being auto paid.***

**Sod Adjustments: Please note customers are responsible for the first 50,000 gallons. If you have not met the 50,000 gallon threshold you will not qualify for a Sod Adjustment.**
Aknowledgement*

I have read and understand the above section.
Account Number*
Date*

MonthDayYear
Date
Type of Adjustment Requested*
Customer Information
Name*

First NameLast Name
Service Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Bill Date Requested for Adjustment*

MonthDayYear
Date
Date Work Performed*

MonthDayYear
Date
Work Performed by:*
Photos of Work

Cancelof
PAID Receipt and Detailed Explanation of Work Completed*

Cancelof
Customer Signature*

Clear
Date*

MonthDayYear
Date
Customer Statement of work completed*
Please provide detailed information of the leak, repair, or sod installation.
Should be Empty:

Customer Information