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Credit Adjustment Request

  1. Hi-Res Seal
  2. City of Rosenberg Customer Service Department
    2110 Fourth Street PO Box 631 Rosenberg, Texas 77471 Phone (832)595-3402 Fax
  3. Credit Adjustment Request
  4. NOTE: Receipts for repairs or parts must accompany a leak adjustment request.
  5. Electronic Signature Agreement*
    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
  6. City Employee's Signature
  7. For office use only
    Cycle _____ Route _____
  8. Leave This Blank:

  9. This field is not part of the form submission.