20B - AA TO FACILITATE PAYMENTS FOR REPAIRS

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Amount of Policy $ As per form Issued I Expires To of SWORN STATEMENT Policy Number 0017471589 In Agency Name Alliant Insurance Services FINAL PROOF OF LOSS COMPANY By the above indicated polity of insurance your insured PEPIP/DEC 2/City of Santa Ana against loss by all risk of physical damage upon the property described, according to the terms and conditions of the said Conditions of the said policy and all forms, endorsements, transfers and assignments attached thereto. 1. Time and Origin: A loss occurred ablout the hour of o'clock M., on the 5th day of February 20 19 The cause and origin of said loss were: Discovery of Mold 2. Occupancy: The building described, or containing the property described, was occupied at the time of the loss as follows, and for no other purpose whatever: 1000 E. Santa Ana Boulevard, Santa Ana, CA 92701 I 3. Title and Interest: When this policy was acquired and at the time of the loss the interest of your insured in the property described therein was sole and unconditional ownership, and no other person or persons had any interest therein or incumbrance thereon. (State exceptions, if any.) NO EXCEPTIONS 4. Changes: Since the said policy was acquired there has been no assignment thereof, or change of ownership, use, occupancy, Possession, location or exposure of the property described, or of our insured's interest therein. (State exceptions, if any.) NO EXCEPTIONS 5. Total Insurance: The total mount of insurance upon the property described by this policy was, at the time of the loss, $ 6. The Cash Value of said property at the time of loss was...................................................................................... $ Not Determined 7. The Whole Loss and Damage was ... ........................................................................................................................ $ 183,434.67 8. The Amount Claimed under the ab ee numbered policy ................................................................................... $ 173,434.67 1 (Amount claimed is net applicable $10,000 deductible) The said loss did not originate by any act, design or procurement on the part of your insured, or this affiant; nothing has been done by or with the privity or consent Hof your insured or this affiant, to violate the conditions of the policy, or render it void; no articles are mentioned herein or in annexed schedules but such as were in the building damaged or destroyed , and belonging to, and in possession of the said insured at the me of said loss; no property saved has in any manner been concealed, and no attempt to deceive the said company, as to the extent oflsaid loss, has in any manner been made. Any other information that may be required will be furnished and considered as part of this proof. The furnishing of this blank it the preparation of proofs by a representative of the above insurance company is not a waiver of any of their rights. FOR YOUR PROTECTION, CALIFORNIA LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. State of (Insured Signature) County of Insured I Subscribed and sworn to (or affirme5i) before me on this day of (month), (year) by proved to me on the basis of satisfactory evidence to be the person(s) who appear before me. (signature of Notary) McLarens File No.: 002.048948.00.J Claim No: 6692409811US 20B-14