Cook County Leak Repair Program Enrollment Form

Participant Information

First Name

Last Name

Other (please specify)

What is your ethnicity?

How did you hear about the Leak Repair program?

Other (please specify)

Participant Contact Details

Phone

Preferred Language

Please provide the language preferred within your household

Participant Address

Street

City

State

Zip Code

Household Information

Home Type

What year was your home built? (estimate if unsure)

How many full bathrooms are in your home?

How many half bathrooms are in your home?

Do you rent or own your home?

If you rent please provide contact information for the homeowner below:

Who pays the water bill?

Other (please specify)

Owner Information

First Name

Last Name

Phone

How can we help?

Select all that apply:

I have a known plumbing leak

I suspect I may have leaks but am unsure whereI have a faucet, toilet, or showerhead in need of repair or replacement with a more water efficient fixtureMy water is currently shut offI have past due water bills (Elevate may be able to help certain participants with past due water bills)

Describe any leaks or plumbing issues you are experiencing:

Income Attestation

Household Size	120% Area Median Income (AMI)
1 person	$94,200
2 persons	$107,640
3 persons	$121,080
4 persons	$134,520
5 persons	$145,320
6 persons	$156,120
7 persons	$166,920
8 persons	$177,600
9 persons	$188,400
10 persons	$199,200

I certify that my household's income is at or below 120% of the Area Median Income. (Please use the table above to determine that your household qualifies)I do not meet the above criteria for income eligibility

Authorization

By completing and submitting this Form you agree as follows:

You are the Owner of the Property, or if you are not the Owner, you agree that you have the consent of the Owner to provide the Owner's contact information.

You have read, and you understand and agree to all Program Terms in this Form below.

You hereby authorize Elevate and each contractor that is engaged by Elevate to perform work for the Program to enter your property, physically or virtually, to perform assessments, determine eligibility for the Program and its sub-programs, prepare a summary of what work is proposed to be completed at the Property under the Program, and to perform such work if approved.

You have the right, and are encouraged, to consult with an attorney if you have questions about this Form and/or the Program Terms below.

Terms and Conditions – Cook County Leak Repair Program

TERMS AND CONDITIONS – COOK COUNTY LEAK REPAIR PROGRAM

These Cook County Leak Repair Program Terms and Conditions (“Terms and Conditions”) are entered into by and between the “Participant” named above and Elevate Energy (“Elevate”). In addition to the authorizations above, and other information in this Enrollment Form, the following are the legal terms and conditions that govern your participation, if approved, in the Leak Repair Program within Cook County’s Water Affordability Program (the “Program”). You understand that by submitting this Enrollment Form you are agreeing to these Terms and Conditions, and that upon submission of this Enrollment Form by you, a binding legal agreement between you and Elevate is formed:

1. Authority. Each person who has completed this Enrollment Form and become subject to these Terms and Conditions represents that such person is the duly authorized representative of the party on whose behalf the person is signing, and that such person has the authority to fully bind that party to these Terms and Conditions. By signing above, each party acknowledges that it has read and understands and agrees to be bound by these Terms and Conditions.

2. Program. Elevate is an Illinois not‐for‐profit corporation that seeks to create a just and equitable world in which everyone has clean and affordable heat, cooling, power, and water in their homes and communities – prioritizing frontline communities. In furtherance of its mission, Elevate administers the Program which is funded by the County of Cook, a body politic and corporate of the State of Illinois (the “County”) through an award to Elevate for the administration and management of the Program pursuant to the American Rescue Plan Act of 2021.

3. Eligibility. You understand that determination of eligibility for participation in the Program is in the sole discretion of Elevate. Elevate complies with all applicable laws including, but not limited to laws regarding non-discrimination and equal opportunity regardless of race, color, religion, sex, sexual orientation, gender identity or national origin.

4. Elevate Obligations.

1. Elevate will process applications, determine eligibility, and gather information about the Participant’s home. Participants will be evaluated based on the supplied information to determine which of the following pathways will address their needs:

1. For Participants in need of water efficiency upgrades:

1. Elevate will share Participant information with contractors. Contractors will coordinate an appointment time with the Participant.

2. Elevate will ensure contractors prepare homeowners for what needs to be done for work to be completed. The contractor will review the summary of work with the Participant, confirming what fixtures are to be repaired/replaced and have any replacement fixtures approved by the participant to finalize the summary of work.

3. Elevate will ensure contractors obtain all necessary permits, outline activities, and estimate the timeline for the work with the Participant.

4. Elevate will have contractors source materials for the repair or replacement of toilets, showerheads, faucets, or other fixtures needing replacement if such fixtures are not WaterSense certified, leaking or in need of repair, or are estimated to be more than 10 years old.

5. Elevate will require that replacement fixtures are of comparable type and quality to existing fixtures, when possible, are WaterSense certified, and are of types/styles that are approved by the Participant. If Participant does not approve the fixture(s) sourced by Elevate or its contractors after a reasonable period of time, Participant shall be in breach of its obligations and Elevate may remove Participant from the Program.

6. Elevate will conduct QA/QC throughout the project.

2. For Participants requiring larger leak repairs:

1. Elevate will perform site assessments at the Property or virtually.

2. Elevate will determine the scope of the project and present the results of Elevate’s assessment to the Participant.

3. Elevate will oversee the recruitment, bidding, and selection process for plumbing contractors to assist with the completion of repairs at the Property and share the results of Elevate’s assessments with the contractors.

4. Elevate will coordinate scheduling of work with a contractor and Participant and/or the affected residents or tenants of the Property.

5. Elevate will inform contractors of their obligations to obtain all necessary permits and require proof that they have done so in accordance with local ordinances.

6. Elevate will have the plumbing contractor address the scope of work as outlined to restore water supply or address leaks.

7. Elevate will require that replacement fixtures are of comparable type and quality, when possible, are WaterSense certified, and are of types/styles that are approved by the Participant. If Participant does not approve the fixture(s) sourced by Elevate or its contractors after a reasonable period of time, Participant shall be in breach of its obligations and Elevate may remove Participant from the Program.

8. Elevate will conduct ongoing QA/QC of construction.

2. For all work determined by Elevate to be warranted under the program (the “Work”), Participant will have the right to approve the Work prior to it beginning. The Work, if any, will be determined in Elevate’s discretion considering measures that will be most effective, Program funds available and Program objectives, among other considerations. Additional measures may be identified during the assessment and at other points throughout the process that may not be covered under the Program, as determined by Elevate in its discretion.

3. Work for which Elevate will engage one or more contractor(s) will be performed at no cost to Participant. Participant agrees that Elevate may rely on Participant’s verbal approval of the Work. Any reference in these Terms and Conditions to “contractor” will mean any contractor Elevate engages to perform Work at the Property. Elevate is not a licensed general contractor and in no event will Elevate be deemed to be, or perform the services of, a general contractor.

5. Participant Obligations. Participant warrants that: (i) Participant owns and manages the Property; and (ii) Participant has the authority to enter into this Agreement and perform Participant’s obligations. Additionally, Participant hereby agrees to:

1. Provide all information to Elevate required for participation in the Program including, but not limited to, demographic information of Participant and/or residents or tenants of the Property.

2. Cooperate with Elevate and any contractor engaged to perform Work, if any.

3. Grant to Elevate, any contractor and their respective employees, agents, subcontractors, and representatives the right to enter the Property for the purposes of performing their respective obligations. If any part of the Property is rented to or otherwise occupied by a third party (each a “tenant”), Participant agrees to be responsible for coordinating the Work with each tenant including, but not limited to, ensuring access to the common areas of the Property and to any space occupied by a tenant of the Property in accordance with all applicable laws (including any law requiring advance notice to tenants). Subject to applicable law, neither Elevate, nor any contractor will have any liability to any Participant or tenant.

4. Be responsible for moving, or causing to be moved, any items blocking access, such as boxes, furniture, appliances, etc. and otherwise preparing the Work site for Work. Neither Elevate, nor any contractor, will be responsible for moving any property of Participant or any resident or tenant of the Property, or preparing the Work site.

5. Not seek to enforce any warranty or claim against Elevate. Participant agrees that Elevate does not warrant the Work and shall not be responsible for the Work or any act or omission of any contractor. All warranties for the Work shall be the responsibility of the contractor that performs the Work, and warranties for any materials or equipment provided, if any, shall be the responsibility of the manufacturer of such materials and/or equipment. Contractors engaged by Elevate will provide a warranty to Participant that all materials and equipment furnished shall be new unless otherwise specified, and that all Work, equipment, and/or materials furnished under the Program shall be of good quality, free from faults and defects, and in conformance with Program requirements for a period of three hundred sixty-five (365) days from the date of completion of the Work, or longer if specified by the manufacturer with respect to the Equipment. In the event of any fault or defect, Owner agrees to pursue resolution through Contractor or the applicable Equipment manufacturer.  

6. Hold harmless on your own behalf, and on behalf of all other persons who could claim by or through you, Elevate and Cook County from any and all claims, causes of action, damages, or losses, of any nature whatsoever, that you may have with respect to the Work authorized.

7. Grant to Elevate a perpetual, non‐exclusive, universal, fully paid‐up license to use any information Elevate or any contractor obtains about the Property for Elevate’s purposes including, but not limited to, providing to one or more contractors in furtherance of the Work, improving the Program and/or creating a case study which does not identify any individual (including Participant and any tenant(s)). Such information may include, but is not limited to, a description of the Work, photographs of the Property, Participant's pre‐ and post‐Work operating costs, and details about the cost of the Work, water savings, lessons learned, and recommendations for future programs and/or services. This license shall be subject to all applicable laws regarding individuals’ privacy and third parties’ intellectual property rights.

8. Comply with all applicable laws including, but not limited to, the Lead Poisoning Prevention Act (410 ILCS 45/) and the Illinois Radon Awareness Act (420 ILCS 46/) which may require Participant to notify current and/or future tenants or prospective purchasers of the Property about lead and/or radon testing and/or remediation. In no event will Elevate be responsible for ensuring Participant’s compliance with any law applicable to the owner or manager of the Property including, but not limited to, any obligation to notify any third party.

9. Maintain the Property in habitable condition.

10. Not interfere with or attempt to modify the scope of Work, if any, approved by Elevate.

6. Termination. Elevate may remove Participant from the Program at any time if Participant breaches any of its obligations, or if Elevate’s agreement with the County is terminated or expires or if funding for the Program ends or is exhausted. Participant may opt out of the Program at any time before seven (7) calendar days prior to Work beginning by providing notice to Elevate.

Occupant Terms and Conditions – Cook County Leak Repair Program

OCCUPANT TERMS AND CONDITIONS – COOK COUNTY LEAK REPAIR PROGRAM

These Cook County Leak Repair Program Terms and Conditions (“Terms and Conditions”) are entered into by and between the “Occupant” named above and Elevate Energy (“Elevate”). In addition to the authorizations above, and other information in this Enrollment Form, the following are the legal terms and conditions that govern your enrollment, if approved, in the Leak Repair Program within Cook County’s Water Affordability Program (the “Program”). You understand that by submitting this Enrollment Form you are agreeing to these Terms and Conditions, and that upon submission of this Enrollment Form by you, a binding legal agreement between you and Elevate is formed:

Authority. Each person who has completed this Enrollment Form and become subject to these Terms and Conditions represents that such person is the duly authorized representative of the Occupant , as defined below, on whose behalf the person is signing, and that such person has the authority to fully bind that party to these Terms and Conditions. By submitting this Enrollment Form, Occupant acknowledges that it has read and understands and agrees to be bound by these Terms and Conditions.

Program. Elevate is an Illinois not‐for‐profit corporation that seeks to create a just and equitable world in which everyone has clean and affordable heat, cooling, power, and water in their homes and communities – prioritizing frontline communities. In furtherance of its mission, Elevate administers the Program which is funded by the County of Cook, a body politic and corporate of the State of Illinois (the “County”) through an award to Elevate for the administration and management of the Program pursuant to the American Rescue Plan Act of 2021. Throughout this document, “Elevate” shall refer to the administer of the Program, “Participant” shall refer to the owner(s) of a property receiving repairs, improvement, or other services under the Program, and “Occupant” shall refer to income-eligible adult tenant(s), renter(s), or lessee(s) residing in a property that is not owner-occupied and that receives repairs, improvements, or other services under the Program.

Eligibility. You understand that determination of eligibility in the Program is in the sole discretion of Elevate. Elevate complies with all applicable laws including, but not limited to laws regarding non-discrimination and equal opportunity regardless of race, color, religion, sex, sexual orientation, gender identity or national origin.

Occupant Obligations. Occupant warrants that: (i) Occupant currently resides at the Property, which is owned by the Participant specified above; and (ii) Occupant has the authority to enter into this Agreement and perform Occupant’s obligations. Additionally, Occupant hereby agrees to:

Provide all information to Elevate required for participation in the Program including, but not limited to, documentation of Occupant’s household income and demographic information of Occupant and/or any other residents or tenants of the Property.

Cooperate with Elevate and any contractor engaged to perform leak repairs and install efficiency upgrades (the “Work”).

Grant to Elevate, any contractor and their respective employees, agents, subcontractors, and representatives the right to enter the Property for the purposes of performing their respective obligations. Subject to applicable law, neither Elevate, nor any contractor will have any liability to any Occupant or other resident of the property.

Be responsible for moving, or causing to be moved, any items blocking access, such as boxes, furniture, appliances, etc. and otherwise preparing the Work site for Work. Neither Elevate, nor any contractor, will be responsible for moving any property of Occupant or any other resident of the Property, or preparing the Work site.

Hold harmless on your own behalf, and on behalf of all other persons who could claim by or through you, Elevate and Cook County from any and all claims, causes of action, damages, or losses, of any nature whatsoever, that you may have with respect to the Work authorized hereunder.

Grant to Elevate a perpetual, non‐exclusive, universal, fully paid‐up license to use any information Elevate or any contractor obtains about the Property for Elevate’s purposes including, but not limited to, providing to one or more contractors in furtherance of the Work, improving the Program and/or creating a case study which does not identify any individual. Such information may include, but is not limited to, a description of the Work, photographs of the Property, Occupant's pre‐ and post‐Work operating costs, and details about the cost of the Work, water savings, lessons learned, and recommendations for future programs and/or services. This license shall be subject to all applicable laws regarding individuals’ privacy and third parties’ intellectual property rights.

Maintain the Property in habitable condition.

Not interfere with or attempt to modify the scope of Work, if any, approved by Elevate.

Termination. Elevate may cease working with Occupant at any time if Occupant breaches any of its obligations, under this Agreement or if Elevate’s agreement with the County is terminated or expires or if funding for the Program ends or is exhausted. Occupant may only opt out of the Program by giving notice to the Participant that owns the Property, who is responsible for providing such notices of intent to opt out to Elevate by no later than seven (7) calendar days prior to Work beginning.

By clicking “Submit,” you are confirming your approval for Elevate (program administrator) to contact you by phone, email, or mail about the Cook County Leak Repair Program.