H04 Change in Tariff

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H04 Change in Tariff

Application for change in tariff



Items marked * must be filled in.

1. Retailer details


2. Supply Point details

Reference to which this allowance relates

Address of premises


3. Request for change in tariff

Service Component for which a change is requested Tariff requested
Potable Water
Non-Potable Water
Foul Sewerage
Surface Water Drainage
Highway Drainage
Trade Effluent

4. Additional information

Please provide any additional information in support of the change of tariff request. If supporting information is provided separately please indicate here. If none please state none. List of items included:


5. Consent to contact the Non-Household Customer

The Wholesaler may wish to contact the Non-Household Customer to arrange a visit to conduct a site assessment. Please indicate whether you give consent for the Wholesaler to contact the Non-Household Customer directly to arrange a visit to the premises.

YesPlease provide contact details below

No

Customer Contact Details

Please indicate if you want to be notified of the date of the visit

Yes

No

6. Declaration

I hereby acknowledge and declare that the information provided in this form is correct and up to date at the date of submission

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