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2 r i i Los Angles * * 2016 Temporary Exemption Application form ecib Contact Inrormation Update submit by January 31,2016 HOUSING + COMMUNITY loves.merit Department Silling Contact: information (on fiia) Pro pert Information APN: SOnOlHDU LUCILLE EVANS 639 W 43RD ST LOS ANGELES CA Statement: Address: HCIDLA SCCFfVKD 639 W 43RD ST LOS ANGELES, CA ^Reni Srab/lizaiion Division Total Units: 2 SOUTH COUIVTEF DO NOT WRITE IN THIS SEGTtON VERIFY BILLING CONTACT INFORMATION if YOU NEED TO CHANGE OR UPDATE INFORMATION, COMPLETE THE SECTION BELOW Name Address (Number, Street, Apt #, City, State, Zip) Phone # Address RENEWAL Exemption Request To renew last year's approved annual exemption(s) listed below, verify the information, fill in the bubble below, sign & date at bottom of page. DO NOT FILL IN THE BUBBLE IF THE SECTION BELOW IS BLANK OR INCORRECT. GO TO STEP 3 TO RENEW EXISTING EXEMPTION(S) LISTED BELOW, FILL IN THIS BUBBLE Code Unit Number T'i RD New Temporary Exemption Request To add, correct, or update Temporary Exemption(s), complete this section. Completed Notarized "Certification of No Collected Form is required if claiming more than two (2) Temporary Exemptions (T1 and/or T3) SEE THE SACK OF FORM EC16 FOR A LIST OF TEMPORARY EXEMPTION TYPES Exemption Code Unit Number(s) RD SC MOT V/RITE IN THIS SECTION TEMPORARY EXEMPTION(S) are to be received by SUNDAY, JANUARY 31, 2016 Return this form in the Exemption Envelope DELINQUENT FEES WILL BE APPLIED IF EC16 Form and/or payment is NOT RECEIVED ON TIME To ensure timely receipt, mail exemption no later than January 21,2016 PAYMENT is to be received by MONDAY, FEBRUARY 29, 2016 Return the 2016 ANNUAL PAYMENT in the Payment Envelope To ensure timely receipt, mail payment no later than February 19, 2016 New, Access On The Go! Simply log into your Account using a Smartphone, Computer, or Tablet at HCiDLAbill.org i j. ssp Hi % Signature Required Belaw By this signature, I dedateunder penajlwof perjury under the laws of the State of California that the foregoing is true and correct. / /s r /- =To'-7-o/4 Date Rev

3 imiy - Los Angeles / Exposition & USC 3625 S Grand Ave Los Angeles, CA Phone: To Evans Lucille 641 W 43rd St Los Angeies, CA al Unit: 0 Customer Transaction Journal Account No /06/ /26/2016 Generated: 05/26/ :25:34 PM Move-in: 09/06/2012 Pay Type: In Advance Paid Thru: 05/31/2016 : Tax: Ins: Due Day: 1 Unit Size: 10.0 x 10.0 Auto Pay: Off Date: 05/10/2016 Date: 05/10/2016 Date: 05/10/2016 Date: 05/10/2016 Date: 05/10/2016 Name: Name: Late Fees Name: Name: Admin (Move in) Fee Name: Prepaid Balance: Balance: Balance: Balance: Balance: Transaction Details Date Transaction Description Unit Price Discount Total Balance PaidThru :08 05/3 0/20! 6 Payment /31/ /01/20i 6 Monthly /10/2056 Payment continued on next page... Page 1 of 16

4 ...Continued from page 3 - Customer Transaction Journal: 09/06/201?. - 05/26/20S 6, al Unit: 0 Date Transaction Description Unit Price Discount Total Balance PaidThru /01/2016 Monthly 0 S /10/2016 Payment - -SI /31/ /01/2016 Monthly /10/2016 Payment 02/29/ /01/2016 Monthly /10/2016 Payment S /31/ /01/2016 Monthly /10/2015 Payment -$> /31/ /10/2015 Payment /30/ /01/2015 Monthly /15/2015 Letter Balance Due Letter 9 - Ltr Cancelled so.oe so.oo 93 19/13/2015 Waive Late Fee Late Fees continued on next page... Customer Service Waived -$ $25.95 SO.OO Page 2 of 10

5 ...Continued from page 2 - Customer Transaction Journal : 99/06/20!2-05/26/2016, al Unit: /13/2015 Payment Resolved $ /31/ /08/2015 Payment 09/30/ /01/2015 Monthly /08/2015 Payment - SO.OO 08/31/ /01/2015 Monthly /10/2015 Payment SS S Si /33/ /01/2015 Monthly insurance S continued on next page.. Page 3 of 10

6 ...Continued from page 3 - Customer Transaction Journal: 09/06/ /26/2016, al Unit: 0 Date Transaction Description 80 05/27/2015 Letter Change Letter New Rate: J# /08/2015 Payment 78 05/01/2015 Monthly 77 04/10/2015 Payment 76 04/01/2015 Monthly 75 O3/10/2015 Payment /31/ /01/2015 Monthly 73 02/09/2015 Payment /28/ /01/2015 Monthly 71 01/10/2015 Payment /31/ /01/2015 Monthly /10/2014 Payment /3i/20: /01/2014 Monthly continued on next page..

7 ...Continued from page 4 - Customer Transaction Journal: 09/05/2012-1(5/26/2016, al Unit: /21/2014 Letter Special Letter J# /09/2014 Payment /30/ /01/2014 Monthly 64 10/05/2014 Payment Rem - - SO.OO 10/31/ /01/2014 Monthly 62 09/10/2014 Payment 09/30/ /01/2014 Monthly 60 08/10/2014 Payment /31/ /01/2014 Monthly 58 07/09/2014 Payment /31/ /01/2034 Monthly 55 06/10/20 >4 Payment 55 06/01/2014 Monthly 743 continued on next page...

8 ..Continued from page 5 - Customer Transaction Journal : 09/06/ /26/20!6, al Unit: /23/2014 Letter Change Letter New Rate: J# /09/2014 Payment SO.OO 05/31/ /01/2014 Monthly 5! 04/09/2014 Payment /30/ /01/2014 Monthly 49 03/09/2014 Payment Insurt /31/ /09/2014 Payment /28/ /01/2014 Monthly 45 01/09/2014 Payment /31/ /01/2014 Monthly 43 12/10/2013 Pay merit /31/ /01/2013 Monthly continued on next page.. Page 5 of!q

9 ...Continued from page 6 - Customer S ransaction Journal: 09/06/ /26/2016, al Unit: 0 Date 1 ransaction Description Unit Price Discount Total Balance PaidThru 41 i 1/27/2013 Letter Special Letter,1# /15/2013 Letter Special Letter J# so.oo 39 11/09/2013 Payment /30/ /01/2013 Monthly 37 10/08/2013 Payment /31/ /01/2013 Monthly 35 09/09/2013 Payment insurance -SI SO.OO 09/30/ /01/2013 Monthly 33 08/09/2013 Payment C8/31/ /01/2013 Monthly insurance 31 07/03/2013 Payment 1 nsurance /31/ /01/2013 Monthly 74S S! $ /10/2013 Payment -$ /30/2013 continued on next page.. Page 7 of IS

10 ..Continued from page 7 - Customer Transaction Journal: 09/06/ /26/2016, al Unit: 0 Date Transaction Description Unit Price Discount Total Balance PaidYhru /01/2013 Monthly $ $ /29/2013 Letter Change Letter 26 05/07/2013 Payment 25 05/01/2013 Monthly insurance 24 04/10/2013 Payment 23 04/01/2013 Monthly 22 03/12/2013 Letter Balance Due Letter - Ltr Cancelled 21 03/10/2013 Payment -$ /31/ /01/2013 Monthly $ $ /12/2013 Letter Balance Due Letter 58 02/10/2013 Payment insurance - Ltr Cancelled -SI $l /28/2013 i7 92/01/2013 Monthly S125.C0 SI /10/2013 Payment continued on next page.. Credit -$ /31/2013 Page 8 of 10

11 _...Continued from page 8 - Customer Transaction Journal: 09/06/ /26/2016, a! Unit: 0 Date Transaction Description Unit Price Discount lota! Balance PaidThru /01/2013 Monthly $ /10/2012 Payment Credit -$ /31/ /01/2012 Monthly $ $ /28/2012 Letter al Agreement J# i 1/27/2012 Letter a) Agreement J# io 11/17/2012 Payment Resolved Late Fees Credit -$ $ /16/2012 Delinquency Pre-Lien Letter PreLien J# ; Ttt 8 11/15/2012 Letter Reminder M $ /11/2012 Delinquency Late Notice Late Charge 1 Gate Lockout Late Fees LateNotice; Cancelled (Invalid $20.00 $20.00 $ /31/ /01/2012 Monthly SO.OO SI S /10/2012 Payment insurance Credit $ $7.50 SO.OO 10/31/20'12 4 i0/01/2012 Prepayment Applied Prepaid 3C.3C $1.50 -$ continued on next page... Page 9 of 10

12 ..Continued from page 9 - Customer Transaction Journal: 09/06/ /26/2016, a! Unit: 0 Rate Transaction Description Unit Price Discount Total Balance PaidThru 10/01/2012 Monthly $ $96.67 $ /06/2012 Payment Admin (Move in) Fee Prepaid Cash -$ $ $7.50 -$1.00 -$ $ /30/ /06/2012 Move-In Admin (Move in) Fee $22.00 $7.50 $ $95.67 $30.50 $22.00 $7.50 $1.00 $30.50 end of report Page 10 of 10

13 Los Angeles / Exposition & USC 3625 S Grand Ave Los Angeles, CA Phone: To Raymond Lewis 639 W 43rd St Los Angeles, CA al Unit: 0 Customer Transaction Journal Account No /30/ /26/2016 Generated: 05/26/ :33:52 PM Move-in: 08/30/2012 Pay Type: In Advance Paid Thru: 05/31/2016 : $ Tax: Ins: Due Day: 1 Unit Size: 5.0 x 15.0 Auto Pay: Off Date: 05/10/2016 Date: 05/10/2016 Date: 05/10/2016 Date: 05/10/2016 Date: 05/10/2016 Date: 05/10/2016 Transaction Details Date Transaction Description Unit Price Discount lio 05/10/20; 6 Payment Credit-Card -S SO.OO 05/31/20! 6 -$ /01/2016 Monthly /10/2016 Payment continued on next page. $ $ $ $ $ /30/2016 -$ Page 1 of -JO

14 /01/2016 Monthly 0 $ $ /10/2016 Payment /01/2016 Monthly /10/2015 Payment 99 12/01/2015 Monthly insurance \0/20! 5 Payment 97 11/01/2015 Monthly 0 $0.0!) 95 10/13/2015 Waive Late Fee Customer Service Waived -$20.40 continued on next page... Page 2 of 10

15 Late Fees -$ /13/20)5 Payment Resolved -$ $ $ /31/2015 $ /01/2015 Monthly 88 08/08/2015 Payment 87 08/01/2015 Monthly 86 07/10/2015 Payment 85 07/01/2015 Monthly -$ $ /10/20! 5 Payment 83 06/01/205 5 Monthly 0 $ $ $ continued on next page... Page 3 of 19

16 82 05/27/2015 Letter Change Letter 81 05/08/2015 Payment 05/31/ /01/2015 Monthly 79 04/10/2015 Payment 74 02/01/2015 Monthly 73 01/10/2015 Payment 72 01/01/2015 Monthly 71 52/10/2014 Payment Page 4 of 10

17 69 15/25/2014 Letter Special Letter J# SO.OO 68 11/09/2014 Payment 66 10/05/2014 Payment 65 10/01/2014 Monthly 64 09/10/2014 Payment 62 08/10/2014 Payment 60 07/09/2014 Payment 59 07/03/2014 Monthly 58 06/1C/2034 Payment 57 06/01/2054 Monthly continued on next page.. $ $ Page 5 of 10

18 insurance $ $ /23/2014 Letter Change Letter New Rate: $ J# /09/2014 Payment 54 05/01/2014 Monthly 53 04/09/2014 Payment 52 04/01/2014 Monthly 51 03/09/2014 Payment 48 02/01/2014 Monthly 47 01/09/20*4 Payment 45 12/i0/20i3 Payment continued on next page... Page 6 of 10

19 43 11/27/2013 Letter Special Letter,1# SO.OO 42 11/15/2013 Letter Special Letter J# SO.OO -SI /30/2013 SO.OO 10/31/ /01/2013 Monthly 37 09/09/2013 Payment 33 07/03/2013 Payment 32 07/01/2013 Monthly continued on next page.. Page 7 of 10

20 31 06/10/2013 Payment 30 06/01/2013 Monthly $ /29/2013 Letter Change Letter New Rate: S Jtf /23/2013 Letter Special Letter J# /07/2013 Payment $ /31/ /01/2013 Monthly 25 04/10/2013 Payment 04/30/ /01/2013 Monthly 23 03/12/2013 Letter Balance Due Letter - Ltr Cancelled 22 03/10/2013 Payment -$ $ /31/2013 2! 03/01/2013 Monthly Si $ $ /23/ /01/2013 Monthly continued on next page..

21 17 01/10/2013 Payment Credit -SI $ /31/ /01/2013 Monthly Credit 12/31/ /28/2012 Letter al Agreement J# /27/2012 Letter al Agreement J# SO.OO 11 11/17/2012 Payment Resolved Late Fees Credit 10 11/16/2012 Delinquency Pre-Lien Letter PreLien J# ; T# 9 11/15/2012 Letter Reminder J# $ $15.00 $ (1705/2012 Month iy $91.00 $ $ /10/2012 Payment Credit -$ $ continued on next page... Page 9 of 16

22 10/01/2012 Monthly $ $ /01/2012 Monthly 08/30/2012 Payment Admin (Move in) Fee Prepaid Prepaid Cash 1 08/30/2012 Move-In Admin (Move in) Fee S22.00 SO.OO $0.58 $5.87 -$4.87 end of report Fage 18 of 1G

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