**You are required to provide a document that verifies your hardship. e.g. police report, insurance claim or financial records. You can attach the document above or send via e-mail (ComEdNPHardship@ElevateEnergy.org) or fax (888-335-3261).

Pursuant to laws and regulations regarding utility customers, Commonwealth Edison Company (“ComEd”) and Elevate Energy and/or its agents, require the applicant to provide the following information and consent to enable Elevate Energy to administer ComEd’s Non-profit Special Hardship Program (“Program”) on behalf of eligible ComEd customers. In the course of its administration of the Program, Elevate Energy 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.

The undersigned Applicant, by its authorized officer or agent, hereby authorizes and gives its consent to Elevate Energy, and its authorized agents, employees, and representatives to obtain and confirm information regarding the Applicant’s ComEd account for electric service at the address provided above. The Applicant also authorizes Elevate Energy to make application for the Program credit(s) to ComEd on its behalf, either directly or via transmission of electronic data through a third party. The Applicant understands and acknowledges that its eligibility for the Program or actual receipt of any benefits from Program shall not relieve the Applicant of any obligation or liability it may have to ComEd, except to the specific and limited extent that any validly approved credit under the ComEd CARE Programs may reduce its liability for services rendered by ComEd.

The Applicant understands that applying for the ComEd CARE Programs does not guarantee that it will receive any benefits and that the ComEd CARE Programs will continue only as long as funds are available or will otherwise terminate according to their terms.

The applicant represents that the account information set forth in this form is true and correct, to the best of its knowledge, and understands and agrees that it may be used by Elevate Energy for the purposes of administering the Program and any related administrative or operational function.