Forms

Medical Certificate Form

A Medical Certificate is written confirmation from a customer’s physician or nurse practitioner that the customer, or someone else living at the property, has a medical condition that would be aggravated if Aqua shut off the water (usually for non-payment). Once received by Aqua, a valid medical certificate gives the customer 30 days to pay the bill or to make payment arrangements.

Send your medical certificate...

By mail:
Aqua America, Inc.
Attention: Collections Department
762 W. Lancaster Avenue
Bryn Mawr, PA 19010

By fax: 866.780.8301  

Download a certificate here

Download Aqua Ohio's Medical Certificate Form here

Download Aqua Illinois' Medical Certificate Form here


Backflow Test Form

Download Backflow Test Form


Texas Service Application
TX - Customer Service Agreement
TX - Customer Service Agreement (Spanish)


Revert to Landlord Permission
Download Revert to Landlord Permission Form