Leak Policy and Adjustment Request Form

2. The City of Edina offers a one-time billing adjustment for water leaks to residential utility customers when a significant increase in water consumption occurs due to a fixture leak, pipe break, vandalism or similar situation.

   A qualified leak adjustment is limited to a maximum of $500 for one quarterly bill. The City will charge the customer for the gallons of water consumed; however, any gallons over the property's four-year average for the corresponding quarter will be adjusted to the Tier 1 rate.

   Customers requesting an adjustment must complete this form. If a completed form meeting the requirements is approved, the credit will be applied to the customer's account within 30 days of submitting the application.

4. First Name*

   Account Holder's Name

5. Last Name*
7. Account Number

   If Known

9. Edina Service Address*

   List the address of the property you are requesting a bill adjustment for. Must be in Edina. 

11. Zip Code*
13. Email Address*
14. Phone Number
16. Description of the Leak*
18. Was the Leak Repaired With a Permanent Fix?*

    1. Yes
    2. No
20. Upload Receipt From Repair Work*

    Please upload the repair work receipt. Note: the City does not reimburse for parts or labor.

22. Upload an Additional Supporting Document

    If you have an additional supporting document, please upload it here.  

24. Billing Adjustment Requirements and Acknowledgment*

    1. I agree with the below statement

    I have read and understand the requirements to receive a billing adjustment (listed on the Utility Billing Division's Leak Policy and Adjustment Request Form page). If my application is approved, I acknowledge this is a one-time adjustment. I certify the information I provided on this form to be true, accurate and complete to the best of my knowledge. I understand that my application may be denied if any information is found to be false, misrepresented or incomplete. 

26. Tennessen Warning*

    1. I have read and understand the below statement

    You are not required to complete this Utility Bill Adjustment Request for Water Leak, but if you do not complete it, you may not receive an adjustment on your utility bill. All the data provided is public data and will be made accessible to anyone who requests it per the Minnesota Government Data Practices Act.

28. Today's Date*
    Today's Date
Leave This Blank:


30. Submit Submit and Print

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