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:
ACO
Attention: Collections Department
762 W. Lancaster Avenue
Bryn Mawr, PA 19010

By fax: 866.780.8301  

By email: nationalcollections@aquaamerica.com

Download a certificate here

Download Aqua Ohio's Medical Certificate Form here

Download Aqua Illinois' Medical Certificate Form here

PA Medical Certificate Guidance 


Backflow Test Form
Download Backflow Test Form


Texas Service ApplicationThe below application is for new customers needing to transfer existing services into their name. If you are needing to inquire about a new water/sewer tap, please reach out to customer service at 877-987-2782.

TX - Customer Service Agreement
TX - Customer Service Agreement (Spanish)
Click here to complete the TX application on-line via DocuSign
Haga clic aquí para completar su solicitud de TX en línea a través de DocuSign


Illinois Residential Water, Sewer Service Application Form 
Download the Illinois Water and Sewer Service Application Form


Revert to Landlord Permission

Download Revert to Landlord Permission Form