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EVERETT <br /> *ASK NOT UN <br /> Exhibit "D" <br /> City of Everett <br /> Community Development Block Grant Program (CDBG) <br /> Small Business Assistance <br /> Microenterprise Report and Verification Form <br /> Owner Name: Owner Address: <br /> Owner email: Best Daytime Phone# <br /> You are receiving assistance through the City of Everett to maintain your business through this COVID-19 <br /> crisis.The assistance is being provided to you as a Microenterprise Business. To qualify as a <br /> microenterprise business, you must have five or fewer employees at the time of receiving assistance <br /> AND,you as owner, must have an annual household income below 80%of the Area Median Income <br /> (below). Please be assured that this information will remain confidential and will be used only to meet <br /> the record keeping requirements of the U.S. Department of Housing and Urban Development, which is <br /> providing the CDBG funds to help stabilize your business. Please complete all sections for the first report <br /> that is due. You do not need to complete SECTION C for the remaining reports due.As soon as you have <br /> completed the information listed below, you return it to the City of Everett Community Development, <br /> 2930 Wetmore Ave., STE 8-A, Everett, WA 98201, ramccrary@everettwa.gov. Thank you for your <br /> cooperation. <br /> SECTION A. <br /> Business still in operation? n Yes. Please explain how the assistance you received helped you <br /> maintain your business. <br /> n No. Please explain. <br /> SECTION B. <br /> Business Name (print please): <br /> Business Address: <br /> Business Telephone <br /> Job Title: full-time or part-time <br /> (circle one) <br /> Page 1 of 3 <br />