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♦ iLY I <br />_ <br />I <br />1 T j 1 Y <br />_ <br />f <br />', RKQG <br />D <br />.¢.S JI r i�^ J r x � <br />M1Y �An4 if <br />e): •1 Ya1 ram/ i r S� r y' <br />jlnj� V 1-I J h <br />�1 <br />rl <br />+. A I <br />Yi' <br />T 5<< <br />�i <br />Certification of Loss of Rent due to the Coronavirus (Exhibit B) <br />The City is required to verify your revenue loss or rent loss due to the Coronavirus to <br />confirm that the City's payment Is necessary. Exhibit B of the template Agreement is <br />the following documentation to demonstrate that the landlord has experienced a loss of <br />rent due to the Coronavirus during this same period last year compared to this year. <br />This information should include the entire property. If you have multiple properties and <br />you are unable to accept payment on behalf of all of them, please list each property <br />separately and provide the name of the property at the top of each list. <br />• Property Name: _Gunther <br />• Property Address: 812 N. Gunther St. Santa An C 9a 2703 <br />® Tax ID for Payment: �"86-32-8123 <br />Total rent payments received between January 1, 2019 to June 30, 2019: <br />$16,530.1 ti <br />• Total rent payments received between January 1, 2020 to June 30, 2020. <br />$ 5,872.90 <br />® Difference in Revenue / Rent between 2019 to 2020 (Subtract 2020 from 2019): <br />-($ 1065725 ) = Revenue Loss or Rent Loss due to the Coronavirus <br />This program is supported with Federal funding. According to Title 18, Section <br />1001 of the U.S. Code, It Is a felony for any person to knowingly and willingly <br />make false or fraudulent statement to any department of the United States <br />Government.'By providing my signature'below, I certify under penalty of perjury, <br />that all the information on this application is correct to the best of my knowledge <br />and belief, and I acknowledge that such information is subject to verification, I <br />also acknowledge that my failure to provide necessary documents within a <br />reasonable period of time or falsification of this Information shall be grounds for <br />my denial of assistance, and that I may be subject to prosecution under the law.1 <br />authorize the release of said information to local, State and/or Federal agencies <br />and to City Santa Ana staff within five years of this date. <br />Landlord Name (Print): Anh Goodman <br />Date: 911612020 <br />Landlord Signature: Date: 9116/2020 <br />Coronavirus Emergency Rental Relief Fund for Landlords Page 44 <br />Application <br />