20B - AA TO FACILITATE PAYMENTS FOR REPAIRS

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Amount of Policy SWORN STATEMENT Policy Number 0017471589 $ As per form In Agency Name Alliant Insurance Services FINAL PROOF OF LOSS Issued Expues July 1, 2018 July 1,19 TO Lexington I I urance Company of Boston, Massachusetts By the above indicated policy 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 forins, endorsements, transfers and assignments attached thereto. 1. Time and Origin: A loss occurred about the hour of o dock _ M., on the 24w day of April 20 19 The cause and origin of said loss were: Mold detected 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 East Santa Ana Boulevard, Santa Ana, CA 92701 1 3. Title and Interest: When this poli6 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.) 1 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..I........................................................................................................................ $ 53,362.17 8. The Amount Claimed under the abc ve numbered policy ................................................................................... $ 43,362.17 (Amount claimed is net applicable $10,000.00 deductible) The said loss did not originati 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 of 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 'hare 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 r 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 affirmea) 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.: 002.049759.00.J Claim No.: 6692409811US r1-