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Certification of Loss of Rent due to the Coronavirus (Exhibit S) The City is required to verify your revenue loss or rent loss due to the Coronavirus to confirm that the City's payment is necessary. Exhibit B of the template Agreement is the following documentation to demonstrate that the landlord has experienced a loss of rent due to the Coronavirus during this same period last year compared to this year. This information should include the entire property. If you have multiple properties and you are unable to accept payment on behalf of all of them, please list each property separately and provide the name of the property at the top of each list. w Property Name: village apts • Property Address: 563 n. tustin ave #d santa ana, ca 92705 • Tax ID for Pavment: 565•84-4471 • Total rent payments received between January 1, 2019 to June 30, 2019: $ s,s00 ® Total rent payments received between January 1, 2020 to June 30, 2020, $ 4,500 Difference in Revenue / Rent between 2019 to 2020 (Subtract 2020 from 2019): _($!,3o0 _) = Revenue Loss or Rent Loss due to the Coronavirus This program is supported with Federal funding. According to Title 18, Section 1001 of the U.S. Code, it is a felony for any person to knowingly and willingly make false or fraudulent statement to any department of the United States Government. By providing my signature below, I certify under penalty of perjury, that all the Information on this application is correct to the best of my knowledge and belief, and I acknowledge that such information is subject to verification. I also acknowledge that my failure to provide necessary documents within a reasonable period of time or falsification of this information shall be grounds for my denial of assistance, and that I may be subject to prosecution under the law. I authorize the release of said information to local, State and/or Federal agencies and to City Santa Ana staff within five years of this date. Landlord Name (Print): iim tamura Date: 09/18/2020 Landlord Signature: Date: 09t18i2020 Coronavirus Emergency Rental Relief Fund for Landlords Page 4 Application