Water Leak Repair Assistance Application

The Portland Water Bureau works with community partners and local plumbers to offer free water leak repair services for eligible customers. Common repairs are leaky toilets, faucets, and underground pipe leaks. Sewer repairs are not eligible. Complete this application to apply for leak repair. (Note: We are not able to reimburse for repairs made outside of the program.)

Please contact us for translation or interpretation, or for accommodations for people with disabilities. More information · Más información · Thêm thông tin · 欲了解更多信 · Дополнительная информация · Mai multe informații · Подробиці · Macluumaad dheeri ah · अधिक सूचना · Tichikin Poraus portlandoregon.gov/water/access · 503-823-6060 (TTY: 503-823-6868, Relay: 711)

Permission to work in your home and share your information

I will answer all the questions on this form completely and truthfully.
I give the City of Portland, Water Leak Repair Program partners, and their contractors permission to evaluate and repair fixtures in my home.
I understand that if my home has existing plumbing problems or maintenance issues, City of Portland, Water Leak Repair Program partners, and their contractors will not be responsible for any damage related to those existing problems.
I agree that I am taking on the risk of having this repair work done in my home.
I give the City of Portland permission to share this application information with the designated Water Leak Repair Program partners and subcontractors so they can coordinate my repair.
I am submitting this information with the expectation that it will be kept confidential and that the City will only release the information if ordered to do so under Oregon’s Public Records Law.

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

Eligibility

Questions about eligibility? We're here to help: 503-823-6060 or leakrepair@portlandoregon.gov

Do you have an active City of Portland drinking water account?

Yes

Water leak repair assistance services are currently only available to Portland Water Bureau customers. For help with referrals to other organizations that may be able to help, please call: 503-823-4527.

Do you own and live in the home where the leak is located?

Yes

Water leak repair assistance services are currently only available to homeowners who live in the home. For help with referrals to other organizations that may be able to help, please call: 503-823-4527.

Are you planning to sell your home in the next year?

Yes

The goal of the Water Leak Repair Program is to help homeowners remain in their homes. The program is not intended to prepare homes for sale. If you have any questions or concerns, please call: 503-823-6060.

Applicant information.

First Name

Last Name

Sewer/Stormwater/Water Account Number

Phone Number

Including yourself, how many people live in the home?

Preferred language (the language we should use to communicate with you)

What is the total monthly income (before taxes) for everyone over 18 living in your home? (By providing your income you may be eligible for additional services from our partners).

Is there anything we can do to help you participate in the program? (Examples might include: assistance understanding or filling out applications, using email instead of phone to communicate, a language interpreter, or using scent-free repair materials.)

Leak description.

Is this a wastewater leak (drain, clog, sewer backup, etc.)?

Yes

I'm not sure.

Date leak was found

Tell us about the leak, and any damage to your home.

Do you still have access to hot water in your home?

Yes

What impact (if any) has the leak had on your quality of life and wellbeing?

Extreme impact

Moderate impact

Some impact

No impact

Don't know

Is this an issue with a leak we have repaired through this program in the past?

Yes

Water-saving devices and more.

We offer free water-saving devices that we can mail out to you (showerheads, faucet aerators, toilet leak detection tablets, and more).

Would you like us to mail you a free set of devices?

Yes

If so, how many bathrooms do you have in the home?

How many standard showerheads do you need?

How many handheld showerheads do you need?

Demographic information

Completion of this section is not required and is therefore completely voluntary. Portland is committed to diversity, equity, and inclusion and uses provided demographic information to help ensure that services reach a broad cross section of community. State and federal law prohibit use of this information to discriminate against you.

Please describe (optional)

How do you identify your gender? Select all that apply.

Woman

Man

Transgender

Non-binary, genderqueer or third gender

Prefer not to answer

Government programs, services, and events sometimes have barriers that prevent people with all kinds of bodies/minds from being part of what we offer. We want to understand and eliminate these barriers. We’re asking these questions so we can plan easier-to-access programs, services, and events.

Do you identify with having or living with a disability?

Yes

I prefer not to disclose

In what year were you born?

Are you an enrolled member, and/or a descendant, of a Federal or State recognized American Indian Tribe or Alaskan Native village/corporation? Mark and describe all that apply.

Enrolled member.

Descendant.

Prefer not to answer.

Tribal affiliation(s):

AAAH & CEP Partner Use Only

This question is for staff use only to indicate direct referrals. If you're not a staff member of one of our leak repair partners, please skip.

Partner Direct Referral

Application Number

You will be provided with a Application Number upon submission.