Self-Declaration Form For Ontario Electricity Rebate on Electricity Bill

Account Information

Name(Required)

First Last

Email(Required)

Account Number(Required)

Service Address(Required)

Street Address City Postal Code

Part 1: Application

I wish to receive the Ontario Electricity Rebate (OER) on my electricity account. My account relates to:(Required)

Please check the boxes that applies to your account

A multi-unit complex that is predominantly residential (e.g. a condominium or apartment building), other than a retirement residence [If you checked this box, fill out Part 2 and Part 6 below]

Any common elements of a multi-unit complex that is predominantly residential [If you checked this box, fill out Part 3 and Part 6 below]

A retirement residence [If you checked this box, fill out Part 4 and Part 6 below]

A mobile home park [If you checked this box, fill out Part 5 and Part 6 below]

Demand for electricity of 50 kilowatts or less

Annual consumption of 250,000 kilowatt hours of electricity or less

You carry on a business that is a farming business for the purposes of the Farm Registration and Farm Organizations Funding Act, 1993, and you hold a valid registration number assigned under that Act or your obligation to file a farming business registration form was waived pursuant to an order made under subsection 22 (6) of that Act

The account is in respect of a long-term care home licensed under the Long-Term Care Homes Act, 2007

Part 2: Multi-Unit Complexes

Multi-unit complexes that are predominantly residential, such as condominium and apartment buildings, are eligible for the OER. To qualify, each of the three statements below must apply. Please check the box next to each statement to confirm it applies to your account. If your account relates to a retirement residence or a mobile home park, do not complete this Part 1; skip to Part 3 or Part 4 as applicable.

My account relates solely to a multi-unit complex^

The multi-unit complex has at least two qualifying units^^

At least 50% of the total number of units in the complex are qualifying units

Total Number of Units

Number of Qualifying Units

Note: A qualifying unit means a unit that, (a) consists of a self-contained room or set of rooms, (b) contains kitchen and bathroom facilities that are for the sole use of the unit, and (c) is occupied and used as a residence; The complex must contain as least 2 qualifying units AND the number of qualifying units must be at least 50% of the total number of units within the complex

Part 3: Common Elements of Residential Multi-Unit Complexes such as Condominium or Apartment Buildings

Starting July 1, 2022, accounts for any common elements of a multi-unit complex that is predominantly residential are eligible for the OER. To qualify, each of the three statements below must apply. Please check the box next to each statement to confirm it applies to your account.

My account relates at least partly to common elements of a multi-unit complex^^^

The multi-unit complex, including any part of the multi-unit complex to which the common area account does not apply, contains at least two qualifying units^^^^

At least 50 per cent of the units within the multi-unit complex, including any part of the multi-unit complex to which the account does not apply, are qualifying units

Part 4: Retirement Residences

Starting July 1, 2022, accounts for a retirement residence will be eligible for the OER. To qualify, each of the four statements below must apply. Please check the box next to each statement to confirm it applies to your account.

My account relates solely to a retirement residence

At least 50 per cent of the units in the facility are occupied or intended to be occupied as a permanent residence by at least one person who is 65 years of age or older and who is not related to the operator of the facility*

There are at least six persons aged 65 or older who occupy or are intended to occupy the facility

The facility is not a long-term care home [if it is, your account may still qualify; please contact us]

Part 5: Mobile Home Parks

Mobile Home Parks

Starting July 1, 2022, accounts for a mobile home park will be eligible for the OER. Please check the box below to confirm it applies to your account.

My account relates solely to a mobile home park**

Part 6: General

You must check each box below and sign the form for your OER claim to be processed.

I confirm that my account does not relate in whole or in part to any of the following types of excluded premises(Required)

• A hotel, motel or 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,
i. 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
ii. 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
• A premises that is identified by a NAICS code commencing with the digits 21, 22, 23, 31, 32 or 33 (“NAICS” means the North American Industry Classification System maintained by Statistics Canada; the codes starting with the digits above relate to premises that include mining, quarrying, oil and gas extraction, utilities, construction and manufacturing)

I Acknowledge(Required)

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(Required)

Field Label(Required)

I confirm that should my account cease to meet the eligibility requirements I will give a revised Notice to Waterloo North Hydro Within 90 days of the date when the change in eligibility occurred(Required)

Name of Account Holder(Required)

Account Holder Name

Signature(Required)

Date(Required)

Self-Declaration Form For Ontario Electricity Rebate on Electricity Bill