Customer Adjustment Request Form

Customer Adjustment Request Form

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

Repairs made by other than a licensed plumber or Contractor require a notarized affidavit of the repair stating when and where the leak was repaired. Dated, paid receipts for parts are to be included.

***Please print the PDF version of this form available on our website if this adjustment request needs to be notarized. You may mail or email the completed form or bring it to our office.***

***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*

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