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EVERETT <br /> .A.I.N61JN <br /> Exhibit "D" <br /> SECTION F. <br /> Duplication of Benefits <br /> Please provide all information about any additional assistance you have received since completing the <br /> original Duplication of Benefits form submitted with your agreement. <br /> Assistance/Source of Funds Amount How were funds expended? <br /> 1 <br /> 2 <br /> 3 <br /> I hereby certify that the information contained on this form is accurate and complete to the best of my <br /> knowledge, under penalty of law and verifiable by federal government representatives. <br /> Signature Date <br /> Page 3 of 3 <br />