Residential Adjustment Form

It is the responsibility of the customer to contact the District to request an adjustment of their water bill through the Adjustment Form. Please complete the Adjustment Form within three (3) months of your affected bill. For any questions on the form, please call our Customer Accounts at (949) 831-2500.

Customers must keep accounts in good standing to avoid incurring any additional fees or charges. It is the responsibility of the customer to contact the Customer Accounts Team to make any payment arrangements if payment cannot be made in full at the time payment is due.

Billed units in Tiers 4 and 5 will be recalculated at the Tier 3 rate for the adjustment. Any approved adjustment will be issued as a credit on a future water bill. Checks will not be issued.

Customer Information

Account Number

Phone Number

Service Address Street Number and Name

City

Zip Code

Adjustment of Charges

Adjustment requests must be submitted within three (3) months of the affected bill, and adjustments will be made only to the most recent bill. If approved, consumption in Tiers 4 and 5 will be recalculated at the Tier 3 rate.

Leak Repairs (including indoor pipe leaks, toilet repairs, irrigation leaks, and pool leak repairs)

Pool Fill (Pool fill request permitted once every five years). Submit *after* affected water bill is received.

New California Friendly Landscapes (Must be installed between November and April). Customer must apply separately for each affected bill during the two (2) month establishment period.

Irrigation Timer Malfunction (Eligible once every three years)

Other reason

Select date of leak repair

Describe the repair

Attach a copy of any receipts, invoices, or documentation for the work performed

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Date of pool fill

Pool Dimensions: Length (ft)

Pool Dimensions: Width (ft)

Pool Dimensions: Average Depth (ft)

Approximate Total Gallons (Width [ft] x Length [ft] x Depth [ft] x 7.48 [gal/cu. ft.])

Describe the reason for pool fill

Attach a copy of any receipts, invoices, or documentation for the work performed.

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Describe the landscaping work performed and plant material used

Attach a copy of any receipts, paid invoices, or documentation for the work performed and/or new plant material. Please also include at least 1 photo of the installed plants.

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Incident (Enter N/A if not applicable)

Explain how the irrigation timer malfunctioned:

Provide details regarding your "Other" request for an adjustment:

Emergency Declaration Reason for Adjustment

As a public agency it is necessary to produce auditable documentation. Attach a copy of any receipts, paid invoices, or documentation for the work performed relating to your issue.

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As a public agency it is necessary to produce auditable documentation. Provide any details regarding your request for an adjustment due to your Irrigation Timer:

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How did you hear about the Bill Adjustment Process?

MNWD Employee

Neighbor / Friend

MNWD Website

Postcard

Door Hanger

Acknowledgement of Terms and Conditions

It is the responsibility of the customer to contact the District and request a bill adjustment when they make a repair or have an issue. Any customers providing falsified information to the District may be liable for back charges. Bill calculations based on falsified information will be recalculated with corrected customer account details.

I affirm that the information contained herein, including attachments, is complete and accurate. I understand acceptable proof may be required for each bill adjustment request at the discretion of the District.

Acknowledgement Agreement

I agree.

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First Name

Last Name

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I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.