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Resident's Name: <br />Resident's Address: <br />EXHIBIT 4 <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 />1. [ I am a Public Housing Resident (Specify Name of the Public Housing Unit): <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 />HOUSEHOLD SIZE <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 />$65,050 or less <br />❑ <br />$65,050.01 or more <br />4 ❑ <br />$72,250 or less <br />❑ <br />$72,250.01 or more <br />5 ❑ <br />$78,050 or less <br />❑ <br />$78,050.01 or more <br />6 ❑ <br />$83,850 or less <br />❑ <br />$83,850.01 or more <br />❑ <br />7 ❑ <br />$89,600 or less <br />❑ <br />$89,600.01 or more <br />❑ <br />8 ❑ <br />$95,400 or less <br />❑ <br />$95,400.01 or more <br />RACIAL BACKGROUND: Mark an "X" below, next to the category that best describes your origin: <br />SINGLE CATEGORIES DOUBLE CATEGORIES <br />Cl American Indian/Alaska Native American Indian or Alaska Native AND White <br />❑ Asian ❑ Asian AND White <br />❑ Black/African American ❑ Black or African American AND White <br />❑ Native Hawaiian/Other Pacific Islander ❑ American Indian or Alaska Native AND Black or African American <br />❑ White ❑ Other— for individuals not identified above. <br />F.IDNIC BACKGROUND: Mark an "X" below, next to the category that best describes your ethnicity: <br />K hispanic/Latino ❑ Not Hispanic/Latino <br />THE UNDERSIGNED DECLARES THAT THE ABOVE INFORMATION IS COMPLETE AND CORRECT. <br />1,57 <br />Signature of Section 3 Residelit Date <br />To Be Completed by Employer <br />The above-named person e"is a permanent full-time emolo eke or ❑ was hired on <br />This perso / I b / Classification is <br />Name of Employer: 1plo l� t � `f b4 <br />� , , I <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 ❑ Very Low <br />Census Tract Number: <br />