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2. No more than one adjustment will be made on an account within a 12-month period.
6. Name on Water Account*
   Please enter the name on the BWA water account for which you are requesting an adjustment.
8. BWA Account Number*
   Enter the BWA Account Number
10. Service Address*
    Enter the service address associated with this account.
12. Phone Number*
14. Email Address*
16. Date(s) of Leak*
    Enter the date or range of dates for the high water bill.
18. Enter the date of and a description of the repair.*
20. Upload Receipt(s)*
    Upload a copy of the paid plumber's invoice. If you made the repairs yourself, please upload a copy of the receipt for parts purchased for the repair.
Leave This Blank:


22. 1. Receive an email copy of this form.
23. Email address

    This field is not part of the form submission.

24. Submit Submit and Print

* indicates a required field