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Leak Forgiveness Request Form

Complete details of the leak forgiveness program are contained in Town of Shelburne Water & Wastewater (Sewer) Collection Policy.

First name

Last name

Service address?

Customer Number (5 digit customer number on your water bill)

Phone number?

What is your email address?

Issue date of invoice with high consumption

Date leak repaired

Brief description of leak issue and how it was repaired

Please attach Proof of Repair. Receipts for parts must be included with the application in order for it to be processed.

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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

Have you received a previous leak adjustment for this property?

Yes

No

To be eligible under the leak adjustment policy, the following conditions must be met:

That this is a residential property and that the water meter services one residential unit/property;
That this residential property was not vacant during the affected period;
The increased water consumption was not due to filling or leakage from a pool/hot tub.

Acknowledgement

By checking this box and submitting this request, I confirm that the above conditions have been met and all of the statements in the leak adjustment form are true and accurate.

Yes

Please sign here (only one property owner required)

Clear

Information is collected under the authority of The Municipal Freedom of Information and Protection of Privacy Act. Questions about the collection of personal information should be directed to the Clerk at 519-925-2600.