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City of Santa Ana <br />22-HHAP-10004 <br />Page 26 of 26 <br />HHAP-3 GRANTEE AWARD DISBURSEMENT INFORMATION <br />ALL APPLICANTS: <br />Instructions: Please fill out the information below, which is needed to process your HHAP Round <br />3 (HHAP-3) initial award disbursement: <br />Administrative Entity/Contracting Agency Name <br />Large City/City of Santa Ana, Community Development Agency <br />Administrative Entity/Contracting Agency Business Address <br />20 Civic Center Plaza, Santa Ana, M-25, CA 92701 <br />Contract Manager Name <br />Terri Eggers <br />Contract Manager Email Address <br />teggers@santa-ana.org <br />Contract Manager Phone Number <br />714-647-5378 <br />Award Check Mailing Address (Include "Attention to:" if applicable) <br />City of Santa Ana <br />Community Development Agency, 20 Civic Center Plaza, M-25, Santa Ana, CA 92701 <br />For grantees who have previously contracted with BCSH, in order to reduce the amount of <br />paperwork needed to process your HHAP-3 award, HCFC is offering the opportunity to use the <br />Tax ID Form (Government Taxpayer ID Form for governmental entities or STD 204 Form for non- <br />governmental entities) and/or Authorized Signatory Form currently on file with HCFC for <br />HHAP-3 award disbursements. You may revoke these authorizations by submitting an <br />updated Tax ID Form or Authorized Signatory Form to hhao@bcsh.ca.gov. <br />Select one: <br />0 The information on the Tax ID Form used for the HHAP-2 award disbursement is accurate, <br />and I am authorizing HCFC to use the previously submitted form for the HHAP-3 initial <br />award disbursement <br />❑ I have included a new Tax ID Form for the initial HHAP-3 award disbursement <br />Select one: <br />❑✓ The information on the most recent Authorized Signatory Form on file with HCFC is <br />accurate, and I am authorizing HCFC to use the form on file for HHAP-3 <br />❑ I have included a new authorized signatory form for HHAP-3 <br />CERTIFICATION <br />I certify that the signature below is authorized to sign for all applicable documents for the HHAP -3 grant <br />on behalf of the Eligible Applicant Jurisdiction listed above. <br />Kristine Ridge, City Manager <br />Name and Title of Authorized Representative <br />Signature of Authorized Representative <br />HHAP-3 Agreement to Apply <br />Published 9/15/2021 <br />9/16/21 <br />Date <br />THE <br />Initial <br />