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EXHIBIT D <br />DRAW REQUEST <br />PAYMENT REQUEST <br />CITY OF SANTA ANA RESIDENTIAL REHABILITATION PROGRAM <br />HOMEOWNER: <br />JOB ADDRESS: <br />RCS: <br />❑ PROGRESS PAYMENT NUMBER <br />❑ CHANGE ORDER # PAYMENT <br />❑ FINAL PAYMENT <br />❑ RELEASE OF RETENTION <br />❑ TERMITE PAYMENT <br />❑ OTHER: <br />PAYEE: <br />PAYEE ADDRESS: <br />AMOUNT REQUESTED: <br />CONTRACTOR (PAYEE) <br />HOMEOWNER <br />The undersigned CONTRACTOR: (1) Certifies that to <br />The undersigned HOMEOWNER: (1) Certifies that to the best of their knowledge, <br />the best of their knowledge, information and belief, the <br />information and belief, the work covered by this Payment Request has been <br />work covered by this Payment Request has been <br />completed to their satisfaction and in accordance with the approved Housing <br />completed in accordance with the approved Housing <br />Rehabilitation Work Contract; (2) Authorizes payment to the CONTRACTOR in the <br />Rehabilitation Work Contract; (2) Certifies that they <br />amount requested, (3) Acknowledges and agrees that inspections by the <br />Residential Construction Specialist (RCS) are performed for financial purposes and <br />have obtained all required building permits, inspections <br />to ensure compliance with program requirements, and should not be relied upon as <br />and approvals for the work covered by this Payment <br />a surety that the work was done properly. <br />Request; (3) Certifies that they have not promised or <br />given the HOMEOWNER a cash payment or rebate. <br />HOMEOWNER (PRINT NAME) <br />CONTRACTOR (PRINT NAME) <br />HOMEOWNER SIGNATURE <br />DATE <br />CONTRACTOR SIGNATURE <br />DATE <br />CITY OF SANTA ANA (RCS) <br />CITY OF SANTA ANA <br />Based on site observations, the undersigned Residential <br />The undersigned certify that to the best of their knowledge, information and <br />Construction Specialist (RCS) certifies that to the best of their <br />belief, this Payment Request has been properly prepared and documented and <br />knowledge, information and belief, the work covered by this <br />authorize the disbursement of funds to cover the amount requested. <br />Payment Request has been completed in accordance with the <br />approved Housing Rehabilitation Work Contract and complies with <br />program requirements. <br />SRCS SIGNATURE DATE <br />EXHIBIT 1 <br />25H -37 <br />