Instructions: Complete this form online and then print it or
click here for the print only version of this form.

• Please request a computer print out from the Water Department prior to the submission of this claim form.
• Attach copy(s) of plumber bill(s) if applicable

1. Claimant's Name:	,
	(Last, First Middle)
2. Street Address:
3. City/State/Zip Code:	/ /
4. Telephone Number:	- D	- E
	(Day and Evening)
5. Water Account Number:
6. Building Address:
7. Billing Period In Question:
8. Nature of Claim:
9. Are You The Owner Of The Property?:	Yes         No
10. Signature of Claimant:
Date:

Mail the completed form, along with any required supporting evidence to:

Office of the City Clerk
Attn: Claims
121 N. Lasalle St.
Room 107
Chicago, IL 60602-1295