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2. 
3. City of Longwood
   WATER LEAK CREDIT ADJUSTMENT
5. IS YOUR ACCOUNT SETUP FOR AUTO DRAFT PAYMENTS?*

   1. YES
   2. NO
7. Applicant Name*
9. Service Address*
11. Account Number
13. Service Start Date
15. Description of Issue
17. Date of Repair*
    (Please be aware of your bill service dates)
19. I have attached a receipt from a licensed plumber

    1. Yes
    2. No
21. I have self-repaired the leak

    1. Yes
    2. No
23. Applicant Signature*
25. Phone Number*
Leave This Blank:


27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

* indicates a required field