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2. 
3. City of Rosenberg Customer Service Department
   2110 Fourth Street PO Box 631 Rosenberg, Texas 77471 customerservice@rosenbergtx.gov(832)595-3400 Phone (832)595-3402 Fax
5. Credit Adjustment Request
7. Date*
   Date
9. Account Number:*
11. Account Name:*
13. Service Address:*
15. Mailing Address:*
17. Phone Number:*
19. List relevant facts for credit adjustment: (Date of repair, what was repaired, etc...)*
21. NOTE: Receipts for repairs or parts must accompany a leak adjustment request.
23. Upload Receipts Here*
25. 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.

    1. I agree.
27. Electronic Signature*
29. City Employee's Signature
    ____________________________________________________________________________
31. For office use only
    Cycle _____ Route _____
Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

* indicates a required field