STRAIGHT TALK CLINIC, INC. 2 -2015

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EXHIBIT B DRAW REQUEST PAYMENT REQUEST CITY OF SANTA ANA RESIDENTIAL REHABILITATION PROGRAM HOMEOWNER: JOB ADDRESS: RCS: ❑ PROGRESS PAYMENT NUMBER ❑ CHANGE ORDER # PAYMENT ❑ FINAL PAYMENT ❑ RELEASE OF RETENTION ❑ TERMITE PAYMENT ❑ OTHER: PAYEE: PAYEE ADDRESS: AMOUNT REQUESTED: CONTRACTOR (PAYEE) The undersigned CONTRACTOR: (1) Certifies that to the best of their knowledge, information and belief, the work covered by this Payment Request has been completed in accordance with the approved Housing Rehabilitation Work Contract; (2) Certifies that they have obtained all required building permits, inspections and approvals for the work covered by this Payment Request; (3) Certifies that they have not promised or given the HOMEOWNER a cash payment or rebate. CONTRACTOR (PRINT NAME) CONTRACTOR SIGNATURE DATE CITY OF SANTA ANA (RCS) Based on site observations, the undersigned Residential Construction Specialist (RCS) certifies that to the best of their knowledge, information and belief, the work covered by this Payment Request has been completed in accordance with the approved Housing Rehabilitation Work Contract and complies with program requirements. 13 HOMEOWNER The undersigned HOMEOWNER. (7) Certifies that to the best of the information and belief, the work covered by this Payment Request has bi to their satisfaction and in accordance with the approved Housing Reha Contract, (2) Authorizes payment to the CONTRACTOR in the amount Acknowledges and agrees that inspections by the Residential Construc (RCS) are performed for financial purposes and to ensure compliance requirements, and should not be relied upon as a surety that the work was HOMEOWNER (PRINT NAME) HOMEOWNER SIGNATURE CITY OF SANTA ANA The undersigned certify that to the best of their knowledge, information Payment Request has been properly prepared and documented and disbursement of funds to cover the amount requested. SRCS SIGNATURE DATE