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City of Santa Ana <br /> 22+WHJ% 04o <br /> Page 26 of 26 <br /> HHAP-3 GRANTEE AWARD DISBURSEMENT INFORMATION <br /> ALL APPLICANTS: <br /> Instructions: Please fill out the information below, which is needed to process your HHAP Round <br /> 3 (HHAP-3) initial award disbursement: <br /> Administrative Entity/Contracting Agency Name <br /> Large City/City of Santa Ana, Community Development Agency <br /> Administrative Entity/Contracting Agency Business Address <br /> 20 Civic Center Plaza, Santa Ana, M-25, CA 92701 <br /> Contract Manager Name <br /> Terri Eggers <br /> Contract Manager Email Address <br /> teggers@santa-ana.org <br /> Contract Manager Phone Number <br /> 714-647-5378 <br /> Award Check Mailing Address (Include "Attention to:" if applicable) <br /> City of Santa Ana <br /> Community Development Agency, 20 Civic Center Plaza, M-25, Santa Ana, CA 92701 <br /> For grantees who have previously contracted with BCSH, in order to reduce the amount of <br /> paperwork needed to process your HHAP-3 award, HCFC is offering the opportunity to use the <br /> Tax ID Form (Government Taxpayer ID Form for governmental entities or STD 204 Form for non- <br /> governmental entities) and/or Authorized Signatory Form currently on file with HCFC for <br /> HHAP-3 award disbursements. You may revoke these authorizations by submitting an <br /> updated Tax ID Form or Authorized Signatory Form to hhap@bcsh.ca.gov. <br /> Select one: <br /> ✓❑The information on the Tax ID Form used for the HHAP-2 award disbursement is accurate, <br /> and I am authorizing HCFC to use the previously submitted form for the HHAP-3 initial <br /> award disbursement <br /> ❑I have included a new Tax ID Form for the initial HHAP-3 award disbursement <br /> Select one: <br /> ED The information on the most recent Authorized Signatory Form on file with HCFC is <br /> accurate, and I am authorizing HCFC to use the form on file for HHAP-3 <br /> ❑I have included a new authorized signatory form for HHAP-3 <br /> CERTIFICATION <br /> I certify that the signature below is authorized to sign for all applicable documents for the HHAP-3 grant <br /> on behalf of the Eligible Applicant Jurisdiction listed above. <br /> Kristine Ridge, City Manager <br /> Name and Title of Authorized Representative <br /> 4:� 9/16/21 <br /> Signature of Authorized Representative Date <br /> HHAP-3 Agreement to Apply 4 <br /> Published 9/15/2021 <br /> Inifinl <br />