25H - AGMT - PERMANENT HOUSING FOR PPL WITH HIV AND AIDS

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EXHIBIT B DRAW REQUEST PAYMENT REQUEST CITY OF SANTA ANA RESIDENTIAL REHABILITATION PROGRAM HOMEOWNER: RCS: ❑ PROGRESS PAYMENT NUMBER ❑ FINAL PAYMENT ❑ TERMITE PAYMENT PAYEE. AMOUNT REQUESTED: CONTRACTOR (PAYEE) The undersigned CONTRACTOR: (1) Certifies that to the best of their knowledge, information and belief, the work covered by this Payment Request has been completed in accordance with the approved Housing Rehabilitation Work Contract; (2) Certifies that they have obtained all required building permits, inspections and approvals for the work covered by this Payment Request; (3) Certifies that they have not promised or given the HOMEOWNER a cash payment or rebate. CONTRACTOR (PRINT NAME) CONTRACTOR SIGNATURE CITY OF SANTA ANA (RCS) Based on site observations, the undersigned Residential Construction Specialist (RCS) certifies that to the best of their knowledge, information and belief, the work covered by this Payment Request has been completed in accordance with the approved Housing Rehabilitation Work Contract and complies with program requirements. 13 25H -15 JOB ADDRESS: ❑ CHANGE ORDER # PAYMENT ❑ RELEASE OF RETENTION ❑ OTHER: PAYEE ADDRESS: HOMEOWNER The undersigned HOMEOWNER: (1) Certifies that to the best of information and belief, the work covered by this Payment Request ha; to their satisfaction and in accordance with the approved Housing R Contract; (2) Authorizes payment to the CONTRACTOR in the amor Acknowledges and agrees that inspections by the Residential Cons (RCS) are performed for financial purposes and to ensure compliai requirements, and should not be relied upon as a surety that the work x HOMEOWNER (PRINT NAME) HOMEOWNER SIGNATURE CITY OF SANTA ANA The undersigned certify that to the best of their knowledge, infounath Payment Request has been properly prepared and documented s disbursement of funds to cover the amount requested. SRCS SIGNATURE DAT