City of Lawrenceburg s1

CITY OF LAWRENCEBURG 100 North Main Street Lawrenceburg, KY 40342

Sewer Bill Adjustment Request

Date: ______

Name: ______Signature: ______

Service Address: ______

Phone Number: ______Account #: ______

Please adjust the Sewer portion of my utility bill. The specific reasons for this request are as follows:

____ *Repaired swimming pool leak: Date: ______

____ *Filled swimming pool: Fill Date: ______Est. Gallons of Water: ______

____ *Water Line break/leak: Repair Date: ______

____ *Plumbing Repairs: Repair Date: ______

Type of Repair: ______

____ *Other (Please Specify) ______

______

Where did the water go? To Sewer ______

------

OFFICE USE ONLY

Monthly Average: $______Monthly High: $______

ADJUSTED BILL FOR ______: $______(Month/Year)

Adjustment: APPROVED / DENIED Reviewed By: ______------

Please attach all receipts for repair expenses. Swimming Pool Adjustments are limited to two (2) adjustments per year.