Please read the following and include the appropriate documentation as listed below:

• Number of People in Household – Water budgets for single-family residential customers are calculated assuming four people per household. If you have more than four people living in your household full-time, you can apply for an adjustment. Customers will receive an additional 52 gallons per day for each additional person. Please include the total number of people living in the household. This type of adjustment expires two years from the adjustment approval date.
• Licensed In-Home Childcare or Eldercare Facility - If a residential dwelling is being used as a licensed childcare or eldercare facility, please include a copy of your business license along with the number of children or elders being cared for at your facility. Customers will receive an additional 52 gallons per day for each additional person. This type of adjustment expires one year from the adjustment approval date. •
• Medical Needs - Please provide verification from your healthcare provider. All medical information will be kept confidential. This type of adjustment expires two years from the approval date.

Before submitting the application, please read the following:

• Information contained in this form is subject to an audit (with up to 10% of all adjustment applications being audited automatically once a year). Should an audit be performed for the residence on the reverse of this form, the applicant agrees to provide acceptable documentation of the actual household population. Such documentation may include, but is not limited to, copies of Federal 1040 tax forms, state issued driver’s licenses or identification cards, birth certificates or voided checks that list the property address in question. Properties that receive an adjustment for In-Home Childcare or Eldercare are also subject to an inspection.
• If any of the information supplied in the application by the applicant is found to be false, and/or proper documentation cannot be provided at the time of an audit, the account will be adjusted retroactively to the date of this application and appropriate fees and charges added to the next water service bill for the address.

Owner Name (required)

Water Service Address (required)

Phone (required)

Email (required)

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Please check reason(s) for adjustment and refer to back of this form for important information.

Number of Full Time Residents in Household (required)

Licensed In-Home Childcare or Eldercare Facility – Number of Children Or Elders: (required)

 Medical needs (must be accompanied by a note from your doctor on their letterhead) (required)

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By signing, I certify that to the best of my knowledge the above information is true and I agree to abide by the terms and conditions as stated above this form. I also understand that the information provided on this application may be subject to verification.

Your Signature (required)

Confirm e-Signature

Review Electronic Records and Signatures Policy (required)

Read our Electronic Record and Signature Disclosure

I agree to use electronic records and signatures

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