Region of Waterloo Form

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Living Here

Required fields are marked with asterisks (*)

Welcome to the Region of Waterloo's high water bill adjustment request form.

This form gathers additional information to determine if an unusually high water bill is eligible for an adjustment.

You can submit this request online (using this form), by email (arwater@regionofwaterloo.ca) or print it off once you are finished entering in all the fields by right clicking and selecting print and mailing your request to:

Region of Waterloo
Financial Services
150 Frederick St, 4^th Floor
Kitchener ON N2G 4J3

Applicant's Name

Service Address

Email Address

Phone Number

Water Bill Account Number

Date of water bill with high consumption

Description of leak or high water issue

Did you have a plumber inspect your home for water leaks?

Yes

Please provide details of plumber findings (if known)

Did you have the leak repaired?

Yes

Please upload a copy of the repair bill

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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

Did you attach a copy of the repair bill?

Yes

Date leak repaired

Meter Reading at Time of Repair

Please enter any enter additional information

Declaration:

I acknowledge and confirm that all of the following statements are true and accurate:

This claim is for a residential property in North Dumfries or Wellesley
The property was not unattended for 5 consecutive days during the billing period in dispute
The increased water usage was not a result of filling of pool, hot tub, lawn watering, irrigation system, leaky toilet or unattended tap.

Notice of Collection of Personal Information

To the extent that the foregoing information constitutes personal information as defined in the Municipal Freedom of Information and Protection of Privacy Act, R.S.O. 1990, Chapter M.56 as amended, the information is subject to provisions of that Act and will be used for the purposes of administering the high water bill adjustment application process. Questions about the collection of personal information should be directed to the Regional Clerk, Region of Waterloo, 150 Frederick Street, Kitchener ON, N2G 4J3 at 519-575-4400.

Please enter today's date

Please sign your signature to confirm you have read both the declaration and Notice of Collection of Personal Information above

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