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FOR LANDLORDS <br />Impacted Tenants List (Exhibit A) <br />This List will become Exhibit A of the Grant Agreement that you will enter into with the City of Santa Ana. <br />Households with a Housing Choice Voucher, also known as Section 8, or those who receive other <br />government rental assistance are not eligible. Tenants that you plan to evict are not eligible. it Is your <br />decision to include which tenants qualify on this list. Please ensure you have: 1) a signed copy of the <br />Lease Agreement verifying occupancy for all tenants on the Impacted Tenants List for whom you are <br />seeking assistance, 2) documentation on rile for all tenants on the Impacted Tenants List that <br />demonstrate that the tenant has been impacted by Coronavirus and have lost jobs, had their work hours <br />reduced, or have experienced a loss of income due to the economic or health Impacts of Coronavirus and <br />who have been unable to maintain their rent payments under their lease agreements. insufflclent or <br />missing documentation may cause a delay in processing or, in some cases, a dental of the application. <br />Additional documentation may be requested during the review of your application. I hereby attest that the <br />Impacted Tenants listed below will be released from any remaining obligation for any rent arrears owed <br />(20'0O) following payment by the City of Santa Ana (80%). <br />The information below may be submitted In a separate spreadsheet attached to Your application. <br />Please include the minimum information below and name it Exhibit A — Property Name " <br />Property Name: Holiday Mobilehome Estates, LP <br />Property Address: 3424 W. Washington Ave. Santa Ana CA 92703 <br />Tax ID for Payment: 33-0433996 <br />Full Name of Tenant <br />(as stated on the <br />Lease) <br />Address of Tenant's Rental Unit <br />Total <br />Amount <br />of Rent <br />Arrears <br />Owed <br />Heidi Simmons 10/1/2020 <br />3424 W. Washington Ave. Sp # 509 Santa Ana CA <br />92703 <br />$1,404.00 <br />Heidi Simmons 11/1/2020 <br />3424 W. Washington Ave. Sp # 509 Santa Ana CA <br />92703 <br />$1,404.00 <br />$ <br />$ <br />Total Amount of Assistance Requested <br />$2,808.00 <br />add add, nai pages ff necessary. If you have multiple properties and you are unable to <br />Coronavirus Emergency Rental Relief Fund for Landlords <br />Application <br />Page 13 <br />