Refund Hearing Request Form

Date

Name

First NameLast Name

Account Number (if known)

Premise Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Preferred way to contact you?

Mailing Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Meter Reading(s)

If the property is served by an inside water meter, please provide the current 7 or 8 digit meter reading. (Include any stationary “0's.”). Alternatively, if you prefer, you may submit a picture of the meter reading along with your form.

Upload picture of meter reading

Meter Reading(s) Date

Main Meter Reading

Outside Remote Reading Device (if possible)

Sub-meter Reading (if applicable)

Outside Remote Reading Device (if possible)

Dispute Information

Disputed Billing Period(s):

Please thoroughly explain your reason for disputing the bill(s) (include all information/documentation pertinent to your dispute)

*Refund amount requested:

*WSSC's fees are required by Maryland law; therefore, this amount should not equal 100% of the billed charges. Additionally, if the property was occupied during the period and water was used, this amount should not equal 100% of the water/sewer charges.

# of people living at the property during the disputed period(s)

# of people living at the property one year before the disputed period(s)

# of people living at the property currently

Hearing Scheduling Information

The hearing will be held at the WSSC Water Support Center building at 14501 Sweitzer Lane, Laurel, Maryland. I prefer to attend the hearing

If in person, for security purposes, please provide the name(s) and phone number(s) for anyone whomay accompany you to your hearing

Legal representation is optional. My own attorney will represent me at the hearing

If yes, please provide your attorney'sname and contact information

I am an attorney