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Water Leak Forgiveness Form - this form must be *notarized*

  1. *Note - This form requires a notarized signature upon completion print, notarize, and return.
  2. 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.
  3. Acknowledgement*
  4. Stop Here - print this form, bring to 101 South Powell Parkway a customer service representative will assist you and notarize.
  5. Leave This Blank:

  6. This field is not part of the form submission.