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14— r �4 <br /> Please enter business name and address <br /> � <br /> � Business legal nmnny G0|OMko F8rOi|� Corporation <br /> � <br /> mBA: R0[nashk@ Bridal � <br /> ` Business street address: 620 SE Everett Mall WQV #225 ^ <br /> - � <br /> ' City,state'�p: EV8F8�, W�\ 98208 . <br /> DESCRIPTION <br /> The Duplication of Benefits(DOB) Reporting form is used to aS5iSt the City of Everett in administering the Everett CARES Snvo0 <br /> Business Grant Program.The form will help to verify all funding a business has received for COVID-19 Pandernic National Emergency <br /> related losses in order to eliminate any duplication ofbenefits. <br /> Receiving funds from other sources does not disqualify you from receiving on Everett CARES Small Business Grant from the City of <br /> Everett,but your business cannot use funds from two sources for the exact same expense.Your business will be asked to document <br /> actual use of the grant funds in Exhibit c: Spending Report. Providing the same document ation/receiptof spending to two different <br /> fund providers will be considered inappropriate "doub|e-dipping." <br /> NOTE:This form requests insurance information(e.0. policy number,insurance name)regardless of whether an applicant submitted <br /> a claim or received funding.This information provides the City the opportunity to verify a participant's information with each <br /> insurance company; this practice is like the data sharing a grant recipient will undertake with SBA or the US Treasury, <br /> PART 1^ OTHER SMALL BUSINESS PROGRAM ASSISTANCE <br /> Assistance received from other business assistance programs used to mitigate impacts from COVID-19 Pandernic National <br /> Emergency.This reporting form must be completed by all businesses that have applied for and/or received any assistance from other <br /> funded Small Businesses Assistance Programs being offered. The information within this reporting form will provide the City of <br /> Everett with vital information for processing the application required by the Stafford Act Section 3112 on Duplication of Benefits. <br /> Provide the narne of the program(s)for which your business is applying or has applied AND any program your business has previously <br /> received funds from (example: "Small Business Administration Loan"). <br /> ` Programs Business has applied to AND received funds from: ^ <br /> ; <br /> � 1 ������ ~� $42,505.00'v ^ n -- - - - ' <br /> � <br /> 2. " <br /> � <br /> ] <br /> 3. <br /> 4, « <br /> m�nEVERETT <br />