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2. Please note:

   FMC 13.04.120

4. Full Name*
5. Email*
7. Home Phone
8. Account Number
10. Service Address*
12. Approximate Day Leak Started*
13. Date Repaired*
15. Description of Leak and Repair Performed*
17. Upload copy of the repair bill / supporting materials
19. Digital Signature - please type your name
21. First Name*
22. Last Name*

24. By completing this digital signature, you are agreeing to the following statement: I am applying for an adjustment to my water and / or sewer bill for the address listed in accordance with the Ferndale Municipal Code section listed previously on this page.

26. Date / Time
    Date / Time
Leave This Blank:


28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit Submit and Print

* indicates a required field