Leak Assistance

Name: *

Address: *

City: *

State: *

ZIP: *

Phone: *

Email Address: *

Account #: *

Date of Event (if known):

Description of event for which relief is requested: *

Relief Requested: *

Acknowledgement: *
I understand that Mid-Dakota’s Request for Relief program is limited to no more than one event per year. If another unintended event occurs within 12-months of the award for this event the new unintended event will not be covered and payment for all water used will be the responsibility of the member at the rate(s) in effect at the time
I understand and agree that by making this Request for Relief I consent to having a “MiNet” ® Portal account activated for the account number listed above. The MiNet Portal will allow me to monitor my water use at this account and set parameters for notification via my email address when water use exceeds set parameters. If I have multiple accounts to be included in the MiNet Portal I will fill out and submit the MiNet Portal application on Mid-Dakota’s website
I have read and understand the above information

Validation:
(For Spam Prevention)

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