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2. All adjustments are applied to the account. Per City Ordinance- If approved you will receive one half of the difference between your average consumption before the leak and the highest usage during the leak, with exceptions. Each customer is allowed one leak adjustment per account in a 12-month period.

4. Customer Name*
6. Address*
8. City*
9. State*
10. Zip Code*
12. Water Account Number*
13. Date of Request*
    Date of Request
15. When Leak Began*
    When Leak Began
16. Date Leak was Repaired*
    Date Leak was Repaired
18. Describe Leak*
20. Upload a copy of plumbing bill or receipt for parts*

    If returning by mail or in person, please attach a copy of plumbing bill or receipt for parts.

    Return by:

    Mail: 

    Water Department 
    PO BOX 928 
    Emporia, KS 66801

    Drop Box: 

    Across from office in South parking lot

    Fax:

    620-343-5668

22. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
24. Electronic Signature*
29. Reason for Denial
Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

* indicates a required field