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2. *Note - This form requires a notarized signature upon completion print, notarize, and return.
4. I do solemnly swear affirm that there was a water leak at the address below that resulted in a high water bill. I further certify that repairs have been made to the water system at this address and I am providing you proof of those repairs, in the form of detailed receipts from certified plumbers, or in the event those repairs were made by me, receipts for any plumbing hardware or supplies. In applying for this water leak forgiveness, I understand that the City of Anna water leak forgiveness Ordinance allows forgiveness only once in every 36 months of service to that customer. I have read this statement and I certify under penalty of perjury the facts contacted herein are true and correct.
6. Acknowledgement*

   1. I agree
7. Full Name*
8. Date
   Date
10. Account No.*
11. Phone Number
13. Street Number*
14. Street Name*
15. Apt #
17. City
18. State
19. Zip
23. Where did the leak occur*
24. When was the leak detected*
26. How was the leak discovered*
28. How and when was the leak repaired*
32. Stop Here - print this form, bring to 101 South Powell Parkway a customer service representative will assist you and notarize.
34. Customer Signature
36. Subscribed and sworn before me on this ____ day of ___________ 20 _______
38. Notary Public in and for the State of Texas
Leave This Blank:


43. 1. Receive an email copy of this form.
44. Email address

    This field is not part of the form submission.

45. Submit Submit and Print

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