25D - AGMT - ALLOCATION NSP 3 - Laserfiche WebLink

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EXHIBIT F k ?1 CITY OF SANTA ANA Housing & Neighborhood Development 20 Civic Center Plaza / 3rd Floor / P.O. Box 1988 / M-26 / Santa Ana, CA 92702 (714) 667-2250 AUTHORIZATION FOR RELEASE OF RETENTION FUNDS Date: Project Number: Homeowner: Address: Santa Ana, CA Telephone #: PROGRESS PAYMENT #: AMOUNT APPROVED: AMOUNT RETAINED (-10%) AMOUNT TO BE DISBURSED: PAYABLE TO: V OFFICE USE ONLY V SOURCE OF FUNDS D HOME CALHOME Ll TAX INCREMENT F1 CDBG AMOUNT TOTAL DISBURSEMENT IDS NUMBER: ESCROW NUMBER: ACCOUNT NUMBER / W.O* CONTRACTOR The undersigned CONTRACTOR certifies that to the best of their knowledge, information and belief, all charges for labor and material incurred by CONTRACTOR and used in construction pursuant to the Housing Rehabilitation Work Contract have been paid in full, and that no liens and/or legitimate claims have been reported. Date Contractor (Signature) HOMEOWNER The undersigned HOMEOWNER: (1) Certifies that to the best of their knowledge, information and belief, the CONTRACTOR has complied with the Housing Rehabilitation Work Contract and that no liens and/or legitimate claims have been reported; (2) Authorizes the release of the retention funds to the CONTRACTOR. Date Homeowner (Signature) CITY OF SANTA ANA The undersigned Residential Construction Specialist (RCS) certifies that to the best of their knowledge, information and belief, the CONTRACTOR has complied with the Housing Rehabilitation Work Contract and is entitled to receive the retention funds withheld during construction. Date Residential Construction Specialist (Signature) The undersigned certify that to the best of their knowledge, information and belief, this Request For Retention Funds has been properly prepared and documented and authorize the disbursement of funds in the amount requested. Date Senior Residential Construction Specialist (Signature) Date Housing Programs Coordinator (Signature) Required Attachments: 02/2004 25D-70