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Resident's Name: <br />Resident's Address: <br />City of Santa Ana <br />SECTION 3 RESIDENT CERTIFICATION FORM <br />(2014 INCOME GUIDELINES) <br />I hereby certify that I am a Section 3 resident, based on the following qualification(s): <br />I . [ I am a Public Housing Resident (Specify Name of the Public Housing Unit): <br />11 <br />2. ❑ I am a low- income resident in the County of , in which the Section 3 <br />covered assistance is expended (Specify the Name of the Section 3 covered construction <br />Check your household size, annual income level (from all sources), and specify racial and ethnic background: <br />1: t"ilifii'�l: c�71fi9ilol <br />INCOME LEVEL <br />❑ <br />1 <br />$50,600 or less <br />❑ <br />$50,600.01 or more <br />❑ <br />2 <br />$57,800 or less <br />❑ <br />$57,800.01 or more <br />❑ <br />3 <br />❑ <br />$65,050 or less <br />❑ <br />$65,050,01 or more <br />4 <br />❑ <br />$72,250 or less <br />❑ <br />$72,250.01 or more <br />5 <br />❑ <br />$78,050 or less <br />❑ <br />$78,050.01 or more <br />6 <br />❑ <br />$83,850 or less <br />❑ <br />$83,850,01 or more <br />❑ <br />7 <br />❑ <br />$89,600 or less <br />❑ <br />$89,600.01 or more <br />❑ <br />8 <br />❑ <br />$95,400 or less <br />❑ <br />$95,400.01 or more <br />RACIAL BACKGROUND: <br />Mark an "X" <br />bellow; next to the category that best describes your origin: <br />SINOLB OATBOORIRS <br />DOUBLE CATBGORtBs <br />❑ <br />American lndian/AlaskaNative <br />❑ American Indian or Alaska Native AND White <br />❑ <br />Asian <br />❑ Asian AND White <br />❑ <br />Black/Al ican <br />American <br />❑ Black. or African American AND White <br />❑ <br />Nattve ktawaiimrlOther Pacific Islander <br />❑ American Indian or Alaska Native AND Black or African American <br />❑ <br />White <br />❑ Other — fnr individuals not identified above. <br />FJIINIC BACKGRDUND: Mark an "X" below, next to the category that best describes your ethnicity: <br />&Hispanic /Latino ❑ Not Aispaoieflatino <br />THE UNDERSIGNED DECLARES THAT THE ABOVE INPORMATIONIS COMPLETE AND CORRECT <br />Signature of Section 3 IBesi t Date <br />To Be Completed by Employer <br />The above -named person eis a permanent frill -time emplovoe or ❑ was hired on <br />This persa .s-s J b J Classification is <br />Name of Employer: -rpep P YET /.,Q nj , <br />To Be Completed by Local Contracting Agency <br />Preference Category: Targeted Service Area ❑ Youth build ❑ McKinney Homeless ❑ Other Section 3 <br />Income Level: ❑Low y Very Low <br />Census Tract Number: <br />23B -37 <br />