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EXHIBIT 4 <br /> City of Santa Ana <br /> SECTION 3 RESIDENT CERTIFICATION FORM <br /> (2019 lwomr GutosLINES) <br /> Res ident'S Name: <br /> Resident's Address: <br /> 1 hereby certify that I am,a Section 3 resident,balled on the following qualification(s)- <br /> 1. [] 1 am a Public Housing Resident(Specify Name of the Pub c.11ou8ing Wit): <br /> I am a low-income resident in the County of , in which the Section 3 <br /> covered assistance is expendt•;c1 (Specify the Name of the Section 3 covered cortstr ction <br /> prof cot): <br /> Cheek your household size,annual income level(fram all sources),find specify racial and ethnic background, <br /> HOUSEHOLD SIZE INCOME LEVEL <br /> El 1 ]] $66,500 or less ❑ $66,500.01 or more <br /> 2 [] $76,000 or less ❑ S76;000;01 or i:noie <br /> ❑ :3 ❑. $85,500 or less ❑ $85,500.01 or more <br /> El 4 $94,950oTless $94,950.01ormore <br /> El 5. ❑ $102,55.0 or less [�. $102,550.01 or more <br /> ❑ 6 $110,ISO or less ❑ s11o,150.01 or more <br /> Fj 7' ❑ $117,75.0 or less ❑ $117,75.0,01 or ulore <br /> D S. ❑ $1.25,350 or less ❑ $125,350.0.1 or more <br /> JRACIM.BACKGROUND:Mh*fin"V below,next to t#ecatsgnry That best deset�he�yirararisut <br /> Sl.Gt, i t: °C'GORI S DQLML.Et;A'rEtORMS <br /> [] Aua Kean lndianVAlnska Native Aruarioan hidlan ar Alavloa Nutive AND White <br /> HAsian Q ASiaaMlllWVhite <br /> Btack/African Artrcrican 0 MAek or African Amcnean AND Whitt <br /> L] Na(ivuHawauaalotl3ern-Leitic1.9wider E] AmeriaatilndianorAlaskaNa[YcA,NO-13]uekoiAfricanAmeiicuu <br /> El 1fiJtriln ®: Odter—for itidividuals notidentitied above; <br /> ETHNIC BACKGRo(1-1D;Mark un"X"Wow.next to the catopty that trait describx.-s your ethnicity: <br /> F HiSgali Actin ❑ Not FlisprnicfUflnu <br /> Ttrrl,UNDEItSIG E.01()ECLARES THAT`IMABOVEINTGtmi`IioN1S CoMPLErE AND CORRECT. <br /> Signature of Section 3 Resident late <br /> To Be Cnrapleted by Employer <br /> The above-named person Q 67 .a permanent Rill tine employee or {] was hired On <br /> Tlus persan's Job Classification is <br /> Name o fE rnployer. <br /> To Be Completed byLocal Con#raetingAgency <br /> Preference Category: []T rgeteil ServiceArea []Youth build ❑McKinney Llomeless ❑Gther Section 3 <br /> lnccrnve Level: EI LM-V []Very Low <br /> Ccmus TractNtttnbor: <br />