1. Claimant's Name:
	(Last, First, Middle)
2. Mailing Address:
3. City/State/Zip Code:
4. Telephone Number:
	(Day and Evening)
5. Water Account Number:
6. Building Address:
7. Billing Period In Question:
8. Nature of Claim:

9. Attach: Dated plumbers bill citing findings and/or repairs.

10. Attach: Computer printout sheet from Deptartment of Water.

11. Are you the Owner of the Property?: Yes    No

12. 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