ANR HOMES, INC. -2011 - Laserfiche WebLink

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EXHIBIT F I?S!1 IF 1'. CITY OF SANTA ANA Housing & Neighborhood Development 20 Civic Center Plaza / 3`c Floor / P.O. Box 1988 / M-26 / Santa Ana, CA 92702 (714) 667-2250 V OFFICE USE ONLY V PROGRESS PAYMENT REQUEST Date: Project Number: Homeowner: Address: Telephone #: PROGRESS PAYMENT #: AMOUNT APPROVED: AMOUNT RETAINED (-10%) AMOUNT TO BE DISBURSED: PAYABLE TO: SOURCE OF FUNDS C HOME f, CALHOME TAX INCREMENT CDBG AMOUNT TOTAL DISBURSEMENT IDS NUMBER: ESCROW NUMBER: ACCOUNT NUMBER / W.O. #: CONTRACTOR The undersigned CONTRACTOR: (1) Certifies that to the best of their knowledge, information and belief, the work summarized on the attached invoice and covered by this Progress Payment Request has been completed in accordance with the Housing Rehabilitation Work Contract; (2) Certifies that they have obtained all required building permits, inspections and approvals for the work covered by this Progress Payment Request; (3) Certifies that they have not promised or given the HOMEOWNER a cash payment or rebate. Date Contractor (Signature) HOMEOWNER The undersigned HOMEOWNER: (1) Certifies that to the best of their knowledge, information and belief, the work summarized above and covered by this Progress Payment Request has been completed to their satisfaction and in accordance with the Housing Rehabilitation Work Contract; (2) Authorizes payment to the CONTRACTOR in the amount requested; (3) Acknowledges and agrees that inspections by the City's Residential Construction Specialist (RCS) are performed for financial purposes and to ensure compliance with program requirements, and should not be relied upon as a surety that the work was done properly. Date Homeowner (Signature) CITY OF SANTA ANA Based on site observations, the undersigned Residential Construction Specialist (RCS) certifies that to the best of their knowledge, information and belief, the work summarized above and covered by this Progress Payment Request has been completed in accordance with the Housing Rehabilitation Work Contract and complies with program requirements. Date Residential Construction Specialist (Signature) The undersigned certify that to the best of their knowledge, information and belief, this Progress Payment Request has been properly prepared and documented and authorize the disbursement of funds to cover the amount requested. Date Date Senior Residential Construction Specialist (Signature) Housing Programs Coordinator (Signature) Required Attachments: Contractors Invoice, Full Release