Sworn Statement For Leak/repair Credit
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1
2SWORN STATEMENT FOR LEAK/REPAIR CREDIT
Customer Name:
Group #:
Customer Number:
Date:
Service Address:
Telephone Number:
I,
, want to make the following
statement under oath:
When was the problem identified:
When was the problem corrected:
Describe where the leak occurred and what repairs were necessary to correct the leak (please make sure you
attach any receipts or repair documentation):
Who completed repair: Self ____ Contractor ____
If Contractor: Name of Company:___________________________________________
Address:________________________________ Phone:_________________________
Initials of Person Making Statement
Page 1 of ________ Pages
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