Refund Request—Excess Water Use Surcharge

Please enter an input in every field, even if it is zero.
Refunds will be credited as a separate line item on the next billing invoice.

    Credit requested by:

    Period to apply credit:


    Tier 1 Surcharges ?

    # of meters

    Excess volume (KGAL)

    Revenue ($1/KGAL)

    3/4" meters

    1" meters

    1 1/2" meters

    2" meters

    3" meters

    4" meters

    6" meters

    Other

    Totals

    $

    Tier 2 Surcharges ?

    # of meters

    Excess volume (KGAL)

    Revenue ($10/KGAL)

    Administrative fee already retained by agency

    Municipal refund amount

    Totals

    Total cost