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EXHIBIT 12 (cont.) <br />4. Efforts made to assist W/MBE in obtaining bonding, lines of credit or insurance, and any technical assistance <br />related to the plans, specifications and requirements for the work which was provided to W/MBE: <br />u>r+s7 s f.-s PAQVPPCP <br />5. Any additional data to support a demonstration of good faith effort, such as contracts with W/MBE assistance <br />agencies: <br />I declare under penalty ofperjury that the foregoing information is true and correct to the best of my knowledge. I <br />understand that the City of Santa Ana and/or the U.S. Department of Housing and Urban Development may verify <br />the information provided herein in connection with W/MBE compliance evaluation/audit activities and that failure <br />to fully and truthfully�e� mp�ete this form may result in economic or other sanctions. <br />Signature: <br />Name: <br />do L. S&ndrzich <br />Title: <br />Vice President <br />Date: <br />03/27/2020 <br />Name of Contractor/Subcontractor: <br />Vido Samarzich, Inc. <br />Contractor/Subcontractor Identification <br />Number: <br />433210 <br />Address (Street, City, State, Zip): <br />6829 Billings Place <br />Rancho Cucamonga, CA 91701 <br />Business Racial/Ethnic/Gender Code: <br />Circle the numeric code which indicates the racial/ethnic/gender character of the owner(s) and controller(s) of 51 % <br />of the business. When 5 1 % or more is not owned and controlled by any single racial/ethnicity/gender category, <br />circle the code which seems most appropriate. <br />C1White Americans <br />2 = Black Americans <br />3 = Native Americans <br />Woman Owned Business: <br />Circle One: <br />Yes or <br />4 = Hispanic Americans <br />5 = Asian/Pacific Americans <br />6 = Hasidic Jews <br />F COCS\PROPSVCS\HUDFORMS%MBU5804AMB-SectionMpec DOC 23A-44 <br />