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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: _ <br />• Property Address:„ <br />• Tax ID for Payment: <br />• Tayments received between January 1, 2019 to June 30, 2019: <br />otal rent p <br />$ 1 .ID <br />• Total rent payments received between January 1, 2020 to June 30, 2020. <br />$ W- U Q <br />• Difference in Revenue / Rent between 2019 to 2020 (Subtract 2020 from 2019): <br />-($ nI - I C> ) = 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. 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): C Date: It it Z�b <br />Landlord Signature: Date: l,- t1 2 <br />Coronavirus Emergency Rental Relief Fund for Landlords Page 14 <br />Application <br />