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2. Please complete this form in its entirety and return to Shreveport Water and Sewerage Department for processing.

4. Customer Information
6. Name*
7. Account Number*
8. Telephone Number*
10. Service Address*
11. Mailing Address*
13. Leak Information
15. Date Leak Detected*
    Date Leak Detected
16. Date Leak Repaired*
    Date Leak Repaired
17. Plumbing Receipts
19. How was leak detected?*
21. Who repaired the leak?*
23. Please attach statement of brief explanation of repairs:*
25. Customer Signature*

    Please type your first and last name.

26. Date*
    Date
28. Email*
30. Payment Requirement*

    All customers requesting a billing adjustment in accordance with these guidelines are required to pay their bill in full or make payment arrangements while this form is being processed.

    1. I understand
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32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

* indicates a required field