E.L.K. Energy Inc. uses this form to determine a customer's eligibility for the Ontario Electricity Rebate ("OER"). Eligibility for the Ontario Electricity Rebate To be eligible to receive the rebate, you must qualify under at least one of the following six criteria. Please check all that apply. To be eligible to receive the rebate, you must qualify under at least one of the following criteria: A multi-unit complex A "common element" of an eligible multi-unit complex A retirement residence A long-term care home (other than an account that is also in respect of a hospital) A mobile home park A farming business I confirm that my account does not relate to the following types of excluded premises. A hotel, motel, motor hotel, resort, lodge, tourist camp, cottage or cabin establishment, inn, campground, tourist home, bed and breakfast vacation establishment or vacation home A trailer park that is not a mobile home park Living accommodation occupied by a person for penal or correctional purposes A hospital A premises that is subject to the Ministry of Correctional Services Act or the Child, Youth and Family Services Act, 2017 Short-term living accommodation provided as emergency shelter Living accommodation provided by an educational institution to its students or staff where: the living accommodation is provided primarily to persons under the age of majority, or all major questions related to the living accommodation are decided after consultation with a council or association representing the residents, and the living accommodation is not intended for year-round occupancy by full-time students or staff and members of their households. A university, college of applied arts and technology or other entity that provides post-secondary education Premises that is identified by a NAICS code commencing with the digits 21, 22, 23, 31, 32 or 33 (i.e. in the mining, quarrying, oil and gas extraction, utilities, construction and manufacturing sectors) E.L.K. Energy Inc. Account Number Name on Account First Last Service Address Address Unit #/P.O. Box City/Town State/Province ZIP/Postal Code E-Mail Address Telephone I consent to the Release of Information. I consent to E.L.K. Energy Inc. disclosing the following information to the Ministry of Energy, Northern Development and Mines: the name of the Account Holder (unless the account is in the name of an individual); where applicable, the Farm Business Eligibility Criteria applicable to the Account; and where applicable, the total consumption of electricity for the period May 1, 2018 to April 30, 2019. I acknowledge the terms. I acknowledge it is an offence to make a false or deceptive statement in a document submitted under the Ontario Rebate for Electricity Consumers Act, 2016 and certify that the information herein is complete and accurate. I confirm that should the account no longer meet the eligibility requirements I will give a revised declaration form to Hydro One within 90 days of the date when the change in eligibility occurred. Name of Authorized Officer Title First Last Signature of Authorized Officer Sign above Signed on this Date