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2. Water Bill Refund Request

   This form is to be used to request a refund of overpayment for a water bill with the City of Westland. Allow 30 to 90 days for reimbursements after the request has been reviewed.

3. 
5. First and Last Name*
7. Water and Sewer Account Number *
9. Service Address*
11. Requested Refund Amount*
13. Reason for Refund*
    -- Select One --Double PaymentOver PaymentCredit ReimbursementWater Escrow Bond(s)Other
15. If other was selected for refund reason, please provide reason:
17. Refund Recipient Information
19. First and Last Name of Recipient*
20. Street Address of Recipient*
21. City, State & Zip Code of Recipient*
23. Phone Number of Recipient
25. Email Address of Recipient
27. Upload the Cancelled Check / Paid Receipt of the Disputed Payment*
29. 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.
31. Electronic Signature*
33. Please allow 30 to 90 days for reimbursement after review of the request. The recipient listed will be contacted if there are any questions.
37. Internal Use Only
39. Supervisor / Director's Approval
Leave This Blank:


41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit Submit and Print

* indicates a required field