SEWER ENTERPRISE FUND

APPLICATION FOR ADJUSTMENT

IN ORDER TO BE ELIGIBLE FOR AN ADJUSTMENT, THIS FORM MUST BE FILED WITHIN 45 DAYS FROM DATE OF BILLING BY COMPLETING & RETURNING TO :

The Department of Public Works

39 Lafayette Road

Salisbury, MA 01952

Fax 978-463-0190

pubworks@salisburyma.gov

Sewer Account # ___________________

Name of Applicant ___________________________________

Service Address ___________________________________

Daytime Phone # ___________________

Mailing Address ___________________________________

Bill Date ___________________

Bill Amount ___________________

Please state reason(s) for this adjustment request and attach a copy of your final water bill.

Subscribed this_____ day of ____________200__ , under the penalties of perjury.

SIGNATURE OF APPLICANT ____________________________________________

A credit will be applied to your account if adjustment is allowed.

Adjustment __________

Signature _____________________ Date __________