Billing Dispute Request Form

* Fields marked with an asterisk are required.

Date of Request*:

Account Type*:

Residential
Non-Residential

Service Holder Information

Business Name:

Prefix:

First Name*:

Middle Initial:

Last Name*:

Suffix:

Cell Phone:

( ) -

Home Phone:

( ) -

Business Phone:

( ) -

Email*:

Mailing Address

Street Address*:

City*:

State / Province*:

Postal / Zip Code*:

Country / Region:

If mailing address is outside the USA.

Service Address

Same as the Mailing Address?:

If you check this box, you will not need to fill out the service address information below.

Street Address*:

City*:

State*:

Zip Code*:

Billing Dispute Details

BWS Account Number*:

Bill Dates(s) in Dispute*:

Character limit: 500. To expand this field, click and drag the bottom right corner of the field.

Amount(s) in Dispute*:

Character limit: 500. To expand this field, click and drag the bottom right corner of the field.

Reason for the Billing Dispute*:

Character limit: 500. To expand this field, click and drag the bottom right corner of the field.

Specific Adjustments to the Bill You Are Requesting*:

Character limit: 500. To expand this field, click and drag the bottom right corner of the field.

Requester Name*:

To complete your request, enter your FULL LEGAL NAME.

Date*:

Security code*:

Enter security code:

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Character limit: 500. To expand this field, click and drag the bottom right corner of the field.

Character limit: 500. To expand this field, click and drag the bottom right corner of the field.

Character limit: 500. To expand this field, click and drag the bottom right corner of the field.

Character limit: 500. To expand this field, click and drag the bottom right corner of the field.

Posted: 05/14/2020

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