Required fields are marked with asterisks (*)

Wastewater Consumption Charge Rebate Form

Customer Information

First name

Last name

Haldimand County Water and Wastewater Account #

Service Incident Location

Address

Phone

Town/City

Postal code

Is your billing location different than your service/incident location?

Yes

Incident Information

Incident date

Repair date

Description of incident

Has an environmental services inspection already taken place?

Yes

All inquiries may be directed to the Accounts Receivable Clerk at 905-318-5932, ext. 6335 or emailed to AccountsReceivable@haldimandcounty.on.ca. Personal information on this form is collected under the authority of the Municipal Act, S.O. 2001, c.25 and will be used to process this form and will be sent to Environmental Services for contacting purposes. The disclosure of this information is governed by the Municipal Freedom of Information and Protection of Privacy Act, R.S.O. 1990, c.M. 56.