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EXHIBIT I <br />Attochmont 2: ExomplC of ExprCSSion of Interest Form <br />The following information is an example of the information that will need to be <br />submitted to the Department of Housing and Community Development by February 12. <br />2021 . The final form will be made available after the Expression of Intent Survey closes <br />on February 3. For questions, please write to: housing(Q1bcs1 r.ca gov. <br />City or County? <br />A) City <br />B Count <br />If a Cily, whal County <br />does your Cily Reside in? <br />Name of City/County <br />Contact (Name, Phone. <br />Name) <br />Email) <br />Phone) <br />Email <br />Secondary Contact <br />Name) <br />Phone) <br />Ernail <br />What is the Size of the <br />A) Over 500,000 <br />Population you Serve? <br />B) Between 200,000 and 499,999 <br />C Under 200,000 <br />If your population is over <br />A) Opt -In to State Rental Assistance Program <br />500,000: <br />(Di(eCl Federal Allocalion+Slole ReServolion Amounl) <br />-or- <br />B) Request Stata Reservation Amount via Block Grant and <br />attest local implementation of Direct Federal Allocation <br />will conform to State Requirements. <br />-or- <br />C) Will not be conforming Direct Federol Allocotion to <br />State Program: Acknowledge that the State will still Serve <br />Jurisdictions' Population through the State Progmni but <br />Jurisdiction assumes responsibility for Duplication of <br />Benefits <br />If your population is over <br />A) Yes, the county/city I represer,l has an exislingg renlol <br />500,000 and you are <br />assistance program <br />Requesting a Block <br />B) No <br />Grant, do you currently <br />have an existing rental <br />ossistancc program? <br />If your population is over <br />$ <br />500,000, you otjted into <br />the State Program and <br />you already requested a <br />UST distribution, what was <br />the value received? <br />City Council 9 — 68 7/6/2021 <br />