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E City of Santa Ana SECTION 3 RESIDENT CERTIFICATION FORM (2014 INCOME Guim WES) Resident's Name; S q h ✓h T .4 a 19 A Resident's Address: I hereby certify that I am a Section 3 resident, based on the following qualification(s): 1, ❑ I am a Public Housing Resident (Specify Name of the Public Housing Unit); 2. ❑ I am a low-income resident in the County of in which the Section 3 covered assistance is expended (Specify the Name of the Section 3 covered construction Check your household size, annual income level (from all sources), and specify racial and ethnic background: HOUSEHOLD SIZE INCOME LEVEL ❑ 1 ❑$61,250 or less ❑$61,250,01 ormore ❑ 2 ❑$70,000 or less ❑$70,000.01 or more ❑ 3 ❑$78,750 or less ❑$78,750.01 or more ❑ 4 ❑$87,450 or less 0$87,450.01 or more ❑ 5 ❑$94,450 or less ❑$94,450.01 or more ❑ 6 ❑$101,450 or less ❑$101,450.01 or more ❑ 7 ❑$108,450 or less ❑$108,450.01 or more ❑ 8 ❑$115,450or less ❑$115,450.01 or more RACI.u. BACKanmeio: Mark an "X" below, next to the category that best describes your origin: SINGLE CATEGORIES D411$I.F CATEGORIES ® American Indian/Alaska Native 0 American Indian or Alaska Native AND White ❑ Asian ❑ Asian AND White ❑ Black/ARican American ❑ Black or A@tcan American AND White HNative Hawadan/other Pacific Islander ElAmadcatIndian or Alaska Native AND Black or African American White ❑ Other— for individuals not identified above. ETHMCBACI(OROU": Mark an'W' below, cast to the category that best describes your ethnioity: Hispanic/Latino ❑ Not Hispanic/Latino THE UNDERSIGNED DECLARES THAT THE ABOVE INFORMATION IS COMPLETE AND CORRECT. Signature of Section 3 Resident Date To Be Completed by Employer The above -named person Ds a permanent full-time employee or Owes hired on Classification: Name of Employer: To Be Completed by Local Contracting Agency Preference Category: ❑ Targeted Service Area ® Youth build ❑ McKinney Homeless [-]Other Section 3 Income Level: ❑ Low ❑ Very Low Census Tract Number: