Winslow IN

P.O. Box 69 Winslow, IN 47598 

812-789-2207

Winslow Economic Development

P.O. Box 69
Winslow, IN 47598

(812)789-2207

townofwinslowin.thriftstorewebsites.com

Online Water Leak Adjustment Request Form


*Date Requested
*Account Number
*Customer Name on Account
*Mailing Address
Service Address (if different than Mailing Address)
*Dates(s) of High Bills
*Repair Date
*Briefly describe the problem and what was done to fix or correct the water leak.
*Will you be receiving any monetary assistance from a third party for this high bill? Please list any sources and amounts
*Will or have you submitted a claim with your homeowners' or tenants' insurance company? If so, what was their response?
*Has a water leak adjustment been made for this service address on any previous occasion? If yes, when?
*How many people reside at the service address?
*Was property vacant or unoccupied when leak occurred? If yes, please provide dates.
*As the customer for the above noted property, I hereby apply for reimbursement under the Adjustment Policy. I confirm that the above information is true and accurate.
*If necessary, how would you like to be contacted? Please provide contact information.
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