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(661) 943-3170

Adjustment Application

5034 W Avenue L • Quartz Hill, CA 93536

Phone Number: 661-943-3170

Fax: 661-943-0457

www.qhwd.org

Please read the following and include the appropriate documentation as listed below:

  • Number of People in Household – Water budgets for single-family residential customers are calculated assuming three people per household. If you have more than three people living in your household full time, you can apply for an adjustment. Customers will receive an additional 52 gallons per day for each additional person. Please include the total number of people living in the household. This type of adjustment expires two years from the adjustment approval date.

 

  • Licensed In-Home Childcare or Eldercare Facility
    If a residential dwelling is being used as a licensed childcare or eldercare facility, please include a copy of your business license along with the number of children or elders being cared for at your facility. Customers will receive an additional 52 gallons per day for each additional person. This type of adjustment expires one year from the adjustment approval date.

 

  • Medical Needs
    Please provide verification from your healthcare provider. All medical information will be kept confidential. This type of adjustment expires two years from the approval date.

 

Before submitting the application, please read the following:

  • Information contained in this form is subject to an audit (with up to 10% of all adjustment applications being audited automatically once a year). Should an audit be performed for the residence on the reverse of this form, the applicant agrees to provide acceptable documentation of the actual household population. Such documentation may include, but is not limited to, copies of Federal 1040 tax forms, state issued driver’s licenses or identification cards, birth certificates or voided checks that list the property address in question. Properties that receive an adjustment for In-Home Childcare or Eldercare are also subject to an inspection.

 

  • If any of the information supplied in the application by the applicant is found to be false, and/or proper documentation cannot be provided at the time of an audit, the account will be adjusted retroactively to the date of this application and appropriate fees and charges added to the next water service bill for the address.