EmailMe Form - Sewage Billing Credit Request Form

Name *

First Last

Service Address *

Street Address City State / Province / Region Postal / Zip Code

Account Number

Phone

### - ### - ####

Email

Requests without either an email or phone number will not be processed

Bill Due Date

MM / DD / YYYY

I am requesting an adjustment/credit to: *

Late Fee(s)

Returned Check Fee

Disconnect Fee

To request an overpayment refund or a leak adjustment, please call (812)244-2343 or email the request to Sewage@TerreHaute.In.Gov. To apply for the Summer Allowance please return the the Sewage Billing Forms main page and choose the appropriate form.

Why do you believe your bill is eligible for an adjustment/credit? *

Note: Completing and submitting this form does not ensure your account will receive a credit. Each request will be reviewed and responded to within 45 days of receipt of an accurately completed submission. Requests lacking specificity may be delayed in receiving a response. Accounts are considered for one (1) lifetime courtesy late fee adjustment according to SBD Policy 1-7. By submitting this form you understand that if an adjustment is granted as a courtesy, the once per lifetime courtesy adjustment allowance will be exhausted.

Check each box to acknowledge *

Completing and submitting this form does not ensure your account will receive a credit. Each request will be reviewed and responded to within 45 days of receipt of an accurately completed submission.

By completing and submitting this form, you acknowledge you are the account holder or a legal representative.

I understand that for leak adjustments or overpayment refunds, I need to call (812)244-2343 or email at SewageBilling@TerreHaute.In.Gov.

I understand that courtesy adjustments are once per account lifetime and that submission of this request may result is processing an adjustment as a courtesy if the account is eligible.