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.***
Aknowledgement
Account Number
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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.Format: (000) 000-0000.
Email
example@example.com
Bill Date Requested for Adjustment

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date Work Performed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Work Performed by:
Photos of Work

Cancelof
PAID Receipt and Detailed Explanation of Work Completed

Cancelof
Customer Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Customer Statement of work completed
Please provide detailed information of the leak, repair, or sod installation.
Should be Empty:

Customer Information