2. City of Waynesboro Pool Adjustment Request Form

   **REQUEST MUST BE AT LEAST 24 HOURS PRIOR TO POOL FILL**

   Submittal of this form is NOT a guarantee that credit will be applied to your utility bill. You will be notified by phone or email if the request is approved, denied or additional information is needed. It is a request form only, and each customer will be allowed only one pool credit per calendar year. Customers account must be paid up to date.  It is the customer’s responsibility to pay their bill in full by the due date while the adjustment request is being reviewed and processed. Failure to pay your utility bill may result in late fees or your water being turned off and your adjustment being reversed if approved. 

4. To determine if your charges may be adjusted, complete the form below and attach the following documents and follow all policy guidelines. 

   • Fill must be for a minimum of 10,000 gallons
   • Call City of Waynesboro Utility Department 24 hours prior to fill. You must talk to a customer service representative. 540-942-6643, option 4. You have 4 days to complete fill. YOU MUST CALL OUR OFFICE BEFORE STARTING. IF CUSTOMER DOES NOT CALL, CUSTOMER FORFEITS THEIR OPPURTUNITY AT A POOL ADJUSTMENT. 
   • Adjustment may take 30-60 days to reflect on billing. 
   • Any past due balances must be paid before applying for pool adjustment. Customer account must be up to date 
8. Date of Request:*
   Date of Request:
9. Start Date of Fill:*
   Start Date of Fill:
11. Account Holder Name*

    Only the account holder or authorized user can make a request for adjustment. 

12. Utility Account Number
14. Service Address*
16. City
17. State
18. Zip
20. Billing Address
22. City
23. State
24. Zip
26. Account Phone Number*
27. Email Address*
29. Purpose For Fill:*

    1. New Pool
    2. Repair
30. If Repair, please provide details:
32. Pool Capacity (in gallons):*
33. Type of Fill*
    -- Select One --FullPartial
35. Dates of New Install or Repair:*
37. Name of Builder/Contractor/Person completing repair:*
41. Signature of Account Holder*

    Only Account Holder or Authorized User can make requests for adjustments.

45. For Office Use Only:

    Beginning Read: _______________Date: ________________ 

    Ending Read: ___________________ Date: _____________

    Total Gallons Used: __________________________________ Approved or Denied: ______________________________

    Amount Adjusted: ___________________________________

    
    

    Customer Service Representative      _____________________________________________                 

    Date_________________

    
    

Leave This Blank:


47. 1. Receive an email copy of this form.
48. Email address

    This field is not part of the form submission.

49. Submit Submit and Print

* indicates a required field