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ATTACHMENT A BOARD MEMBER INFORMATION As a board member of a designated Community Housing Development Organization (CHDO), please provide the following information. BOARD MEMBER NAME: ADDRESS: PHONE #: OCCUPATION: PLEASE CHECK ALL OF THE FOLLOWING THAT APPLY TO YOU: O I am a resident of a low-income neighborhood. (This does not mean that you must qualify for low-income status, only that your residence is located in a low-income neighborhood where at least 51% of the residents have an annual gross income less than 80% of the current Area Median Income.) () I am a low-income resident of the community. (Low-income is defined as less than 80% of the Area Median Income. Community is defined as: neighborhood, city, county, or metropolitan area.) () I am an elected representative of a low-income neighborhood organization. (Low-income organizations are composed primarily of residents of a low-income neighborhood. Examples of such organizations are: block groups, neighborhood watch organizations, civic associations, neighborhood church groups, etc. The group must be a neighborhood organization and may not be the CHDO itself.) () I am a representative of the public sector, (A public sector representative is any elected public official, any appointed public official, any public/government employee of a public agency or department, or any individual who is appointed by a public official to serve on a CHDO board.) ( ) None of the statements above apply. I certify that the information is true and correct. Board Member Signature Member Printed Name Title Date ss e City of Santa Ana Community Development Agency Request for Qualifications for Community Housing Development Organizations (CHDO) Page 25 19F-28