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EXHIBIT 4 <br />City of Santa Ana <br />SECTION 3 RESIDENT CERTIFICATION FORM <br />(2014INCome GUIDBLINe3) <br />Resident's Name: <br />Resident's Address: <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 />❑ <br />$50,600 or less <br />❑ <br />$50,600.01 or more <br />❑ <br />2 <br />❑ <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 />❑ <br />4 <br />❑ <br />$72,250 or less <br />❑ <br />$72,250.01 or more <br />❑ <br />5 <br />❑ <br />$78,050 or less <br />❑ <br />$78,050.01 or more <br />❑ <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: Mark an "X" below, next to the category that best describes your origin, <br />SINGLE CATEGORIES <br />DOUBLE CATEGORIES <br />❑ Americanlndian/AlaskaNative <br />❑. American Indian or Alaska Native AND White <br />❑ Asian <br />❑ Asian AND White <br />❑ Black/African American <br />❑ Black or African American AND White <br />❑ Native Hawaiian/Other Pacific Islander <br />❑ American Indian or Alaska Native AND Black or African American <br />❑ white <br />❑ Other— for individuals not identified above. <br />ETHmCBACKGROUND: Mark an "Y' below, next to the category that best describes your ethnicity: <br />❑ Hispanic/Latino ❑ Not Hispanic/Latino <br />THE UNDERSIGNED DECLARES THAT THE ABOVE INFORMATION IS COMPLETE AND CORRECT. <br />Signature of Section 3 Resident Date <br />To Be Completed by Employer <br />The above-named person ❑ is a permanent full-time employee or ❑ was hired on <br />This person's Job Classification is <br />Name of Employer: <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 />