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Certificationof f 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 />separatelyiand provide the name of the property at the top of each list. <br />• Property Name: i31 u npyV , <br />Property Address:—_p <br />6bw ("4 a1,L- V ,Tax b for Payment: c <br />Total rent payments received between January 1, 2019 to June 30, 2019; <br />Total rent payments received between January 1, 2020 to Juno 30, 2020. <br />• Difference in Revenue / Rent between 2019 to 2020 (Subtract 2020 from 2019): <br />"($ '1 & 1-16. ?) = Revenue Loss or Rent Loss due to the Coronavirus <br />This program is supported with Federal funding. According to Title 18, Section <br />1®t)7 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, 1 certif <br />that all the information on this appliy under penalty of perjury; <br />cation 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. I <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): g <br />Date: <br />Landlord Signature: Date. Alu,lv <br />t .1 <br />Coronavirus Emergency Rental Relief Fund for Landlords <br />Application Page 14 <br />