Leak Adjustment Request Form

Leak Adjustments approved by Jackson County Water Utility, INC can save a member 40% of leak and can include up to three consecutive months. Members can only take a leak adjustment if repairs have been made and member has had a true leak. Leak adjustments do not include filling of swimming pools or high usage. Only one leak adjustment every 5 years is allowed per membership.

Member Name

Contact Number(required)

Service Address of Leak

Location Of Leak On Your Property

Approximate Leak Dates
to
Date Water Utility Was Notified Of Leak

Date Leak Repaired

Who/Whom made leak repairs

Note: if you have a certification or receipt of who/whom make leak repairs please email to billing@jacksoncountywater.com or provide a copy to office staff.

I affirm under the penalty of perjury that I (Member) have repaired the leak at the address stated above and have not had a leak adjustment on any prior accounts in the last 5 years.

Signature (Type your name)

Date (Type today's date ex.. 01/01/2020)

Security Code