Billing Adjustment Request

Billing Adjustment Request
Account Number*
Applicant's Information
Applicant Name*

First NameLast Name
Daytime Phone Number*
Add your best contact to reach you.
E-mail Address*
example@example.com
Is the service address the same as the billing address?*

YesNo
Service Address*

Street Address

Street Address Line 2

CityState

Zip Code
Billing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Situation

Briefly describe the reasons, circumstances, or other justification for receiving a credit on the sewer portion of your bill. All credit requests must include copies of invoices, receipts, or documentation for repair or replacement of what contributed to the increase in water consumption. Toilet leaks do not qualify for sewer credits.
Describe Your Situation*
Upload copies of invoices, receipts or other documentations in reference to the situation.*

Max file size: 25 MB, Accepted file types: .pdf, .jpg, .png
Cancelof
Applicant Agreement

Applicant must read and sign
I agree that the information I have provided is true, complete, and accurate. I understand that credits are issued as a courtesy and all requests are subject to review at the discretion of the City of Coral Springs Water Billing Department. I understand that I will be billed for all utility services charged at the above address until such time that services are discontinued. I am responsible for paying for the utility services. I understand I am billed monthly and I have 25 days to pay or else one percent (1%) late fee will be applied to all balances. (Chapters 17 & 22 from the City’s Code of Ordinances.)
By typing my name in the below space, I am electronically signing this form. My signing this electronic signature certifies the information to be true, accurate, and complete.*

First NameLast Name
Date Submitted

MonthDayYear
Hour MinutesAM/PM Option
Should be Empty:

Billing Adjustment Request

Applicant's Information

Situation

Applicant Agreement