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PART 4. ATTACHMENTS <br /> Attachments to document Insurance Coverage.The following information is required to be provided to the City of Everett as <br /> documentation with the completed Duplication of Benefits Form. <br /> 1. Each insurance policy in force on or after March 13,2020 <br /> 2. All correspondence relating to the insurance policies in force on or after March 13,2020,including correspondence regarding <br /> any claims filed. <br /> 3. Documentation for each of the sources of funds acquired as a result of the March 13,2020 COVlD-1.9 Pandemic National <br /> Emergency. <br /> PART 5. SIGNATURE(S) <br /> By submitting this Insurance Information,the Applicant(s)acknowledge and understands that Title 18 United States Code Section <br /> 1001:(1) makes it a violation of federal law for a person to knowingly and willfully(a)falsify,conceal,or cover up a material fact; (b) <br /> make any materially false,fictitious,or fraudulent statement or representation;OR(c) make or use any false writing or document <br /> knowing it contains a materially false,fictitious,or fraudulent statement or representation,to any branch of the United States <br /> Government;and(2)requires a fine,imprisonment for not more than five(5)years,or both,which may be ruled a felony,for any <br /> violation of such Section. <br /> Sign and date <br /> 12/16/2020 <br /> Date <br /> grg a 6-0,4— Miguel Gonzalez <br /> A lica Signature Print Applicant Name <br /> pP g PP <br /> Joint Applicant Signature Print Joint Applicant Name <br /> Continued... <br /> EVE R E TT Everett CARES 5maf1 Business Grant Program Round 3 ' page 11 <br />