INFORMATION REQUEST AND CONSENT FORM
(ComEd CARE Program)
Pursuant to laws and regulations regarding utility customers, Commonwealth Edison Company ("ComEd") and Center for Neighborhood Technology and/or its agents ("CNT"), require the applicant to provide the following information and consent to enable CNT to administer ComEd's Non-Residential Rate Relief Program ("Program") on behalf of eligible ComEd customers. In the course of its administration of the Program, CNT may request that credits be provided directly to ComEd customers eligible for the Program and any related assistance, in accordance with ComEd's policies and practices. The following information and consent shall be provided by ComEd customers for the purpose of participating in the Program.
Please complete all of the requested information thoroughly. Incomplete or incorrect forms may delay or result in a denied application by CNT.
CONSENT FOR ACCOUNT INFORMATION
I hereby authorize and give my consent to Center for Neighborhood Technology and its authorized agents, employees, and representatives (collectively referred to as "CNT") to obtain and confirm information regarding my ComEd account for electric service at the address provided above. I also authorize CNT to make application for the Program credit(s) to ComEd on my behalf, either directly or via transmission of electronic data through a third party. I understand and acknowledge that my eligibility for the Program or actual receipt of any benefits from the Program shall not relieve me of any personal obligation or liability I may have to ComEd, except to the specific and limited extent that any validly approved credit under the ComEd CARE Program may reduce my liability for services rendered by ComEd.
I understand that applying for the ComEd CARE Program does not guarantee that I will receive any benefits and that the ComEd CARE Program will continue only as long as funds are available or will otherwise terminate according to their terms.
I represent that the account information set forth in this form is true and correct, to the best of my knowledge, and understand and agree that it may be used by CNT for the purposes of administering the Program and any related administrative or operational function.