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(9) <br />ACCOUNT NUMBER REP4RTN€3 PERIOD: TO <br />HGTELfMOTEL NAME'_ <br />PAb1PEFrr9r ADDRESS: C4fE: <br />SEE REVERSE SIDE OF 7HIS FORM FOR INSTRUCTIONS <br />1} TOTALNUYBE7t OFHOTELfMCTELRO7M8: R) TOTAL NU\A�ER OF:]OM5'NI-i PERhIANEHT RE8I0ENTS, <br />.r.=rttb..lxn FIERIAME TREUNNT—bnUXT13HK-1h. H.�lih4ni <br />I- GROSS RENT FOR ALL ROOMS................................................................................................................. 5 <br />2. LE2BALLOWABLE13E13UG7KM: <br />d Poet Flom Pemenent Reskerb {See 9487RUC-T13N X2a- as+ese:kk d ENs item} ; <br />GoNernmelrl ErrploMEYempIIom {See NBTRUOTICNX2b- as+ese:kk d tNs item} i <br />r_ Qthe ExcmYlons {See NBTRLOTICNX21-n-mse stle oT this fo" ; <br />]L TOTAL OEDLIGT]ONB iLkne A ptus Une Bills LireQ ...... .................................... i <br />4_ TAXA13LE IEWra R-Yle 1 mhus Lrrc 3] ........ ................... ...... i <br />5- IETTAXjll%Of LFrt4j .............................................................. _....... ........................................... i <br />NL LATEPENPLTIE8410%) {See NBTRUOTICN XS- revesc skis afttls lxmj .................. ............ € <br />7_ NTEREST irH&RBE f1.3% Pc• Month} {See NBTRUOTICN XS- resew skk of ltls iorm................... ............ 5 <br />L TOTAL AMOUhR ELIE{Sum arLlnes 51roullh 71—......... .............................................. ............... 5 <br />Imawe under me pKwft'N ps", "me rampmv slgdeRJ m aye" m eq anacal74 we b me bemcirmykwwjadgean m.Aw <br />810NATURE OF HOTEUMOTEL AUTHORIZED A13ENf <br />PR/YT NALE OF HGTEUMOTEL.ALITMR12E0 AAEW <br />DATE <br />TIE EPHONE NUMEBt EXT- X <br />h4UL STATEMENT AND PAYMEWTO: CITY OF aAINTAAK&HG7EL%nSr C]RB TAX, LHS. Pa BDX 19K BANTA ANA4 Ch97N1-1 WA. <br />GENERAL CKN=ONB REGARDING 71# FORM ORTFE EIOTEL VIBrrDRS TAX B44GUL13 BE GIRE=13 TC: t714] 647-54M. <br />CITY OF SANTA ANA <br />CITY OF 8 NTA ANA <br />,1 20 CWl, C>EITER FLi3A - Pa BDX 1964, M-15 <br />r �{ BANTAhN& CALIFORNIARZK11 -IN4 <br />'tiLtiiiiSi3a7� PHONE NUMBER FS41647i494 <br />AF <br />ACCOUN-NUMBED <br />HOTELAMOTEL ✓MAkIE: <br />PROPERTY ADDRESS: <br />REPORTING PERIOD- TO <br />DUE DATE: <br />PAID AI IT (LINE a ABCV4 <br />FOR PROPOSERS' REFERENCE ONLY <br />City of Santa Ana RFP No. 23-165 Page 58 of 196 <br />