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FOR LANDLORDS Certification of Loss of Rent due to the Coronavirus (Exhibit 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. • Property Name: Pacific • Property Address: 2101 S. Pacific St., Santa Ana • Tax ID for Payment: • Total rent received between January 1, 2019 to June 30, 2019: • $Total rent payments received between January 1, 2020 to June 30, 2020. • Difference in Revenue / Rent between 2019 to 2020 (Subtract 2020 from 2019): -($ 1ZM ) = 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 C1,-.nial Of 85SISt?iICP; and that I rna) i?=-ub)Bat t0 elf"OSnmi'lin? unrinr til P_ 134'/, 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): /�f/A& 7- tf ` CC, /A 1A N '� a Date: /D -I2 — // Landlord Signature: 1.. Date: /1 12—z-,e) Coronavirus Emergency Rental Relief Fund for Landlords Page 14 Application