Form Center

Request for Sewer Credit Application

2. 
3. 2 S Orlando Avenue Cocoa Beach, FL 32931
4. Phone: (321) 868-3253 CityOfCocoaBeach.com
6. The following rules and restrictions apply:

   1. The request for sewer credit application must be fully completed.
   2. Requests must be received within 90 days of the bill date.
   3. One adjustment is permitted in an eleven (11) month period for water lost through leaks.
   4. One adjustment is permitted in an eleven (11) month period for water used for pool fills.
   5. Administrative fee will be deducted from any credit adjustment granted.
8. Please Note: SEWER CREDITS ARE NOT GUARANTEED, nor granted due to the following:
   Broken or leaky water lines resulting in water entering the sanitary sewer system ( i.e. leaky toilets, inside faucets, etc.) or careless/undetermined use of water.
10. REASON FOR HIGH CONSUMPTION*

    A Representative from the Finance Department will contact you for documented repair invoice or bill of parts. Please be aware that a request cannot be processed until verification of repair is provided.

    1. Pool Refill
    2. New Pool Refill
    3. Pool Repair
    4. Leak Repair

    1. Outside Hose
    2. Outside Irrigation
    3. Other
12. Number of gallons used to fill pool:*
14. Please describe*
16. Service Address*
18. City
19. State
20. Zip
22. Phone Number
23. Email Address
25. Account Number*
27. First Name
28. Last Name
29. Date
31. Acknowledgement*

    1. I understand that by checking this box constitutes a legal signature confirming that I am the account holder requesting a sewer credit above.
33. E-MAIL DISCLAIMER
    Under Florida law, e-mail addresses are public records. If you do not want your e-mail address released in response to a public records request, do not send electronic mail to this entity. Instead, contact this office by phone or in writing.
Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field