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FOR LANDLORDS <br />.'I <br />Certification of Loss of Bent due to the Coronavirus (Exhibit <br />The City is required to verify your revenue loss or rent loss due to the Coronavirus to <br />confirm that the City's payment is necessary. Exhibit B of the template Agreement is <br />the following documentation to demonstrate that the landlord has experienced a loss of <br />rent due to the Coronavirus during this same period last year compared to this year. <br />This information should include the entire property. If you have multiple properties and <br />you are unable to accept payment on behalf of all of them, please list each property <br />separately and provide the name of the property at the top of each list. <br />Property Name: <br />* Property Address: <br />* Tax ID for Payment: <br />N.rj,JQV,Q! <br />1501E =1rat S18,}Na Ana, Ca92705 <br />94481614.E <br />+ Total rent payments received between January 1, 2019 to June 30, 2019: <br />$ ? L-j �ti_, f__• _� <br />Total rent payments received between January 1, 2020 to June 30, 2020. <br />3 i `_ <br />Difference in Revenue/ Rent between 2019 to 2020 (Subtract 2020 from 2019) <br />-($ 1 r-t' B' ! 3 .' } = Revenue Loss or Rent Loss due to the Coronavirus <br />This program is supported with Federal funding, According to Title 18, Section <br />1001 of the U.S. Code, it is a felony for any person to knowingly and willingly <br />make false or fraudulent statement to any department of the United States <br />Government. By providing my signature below, I certify under penalty of perjury, <br />that all the information on this application is correct to the best of my knowledge <br />and belief, and I acknowledge that such information Is subject to verification, I <br />also acknowledge that my failure to provide necessary documents within a <br />reasonable period of time or falsification of this information shall be grounds for <br />my denial of assistance, and that I may be subject to prosecution under the law. I <br />authorize the release of said information to local, State andfor Federal agencies <br />and to City Santa Ana staff within five years of this date. <br />Landlord Name (Print): Tessa Ma oo _ Date: U d 2-.' <br />,I 1 rr <br />Landlord Signature: �ir Date: ll. t 2.+ l <br />Caronavirus Erne!gency Rents; Re(ie Fr 4nd for landlords Page 1 <br />App lira ti or <br />