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PART 2, INSURANCE <br /> Insurance assistance received hzrC0V|O-1g Pandemic National Emergency related losses. Insurance company information must he <br /> completed even if the business did not receive insurance monies as compensation for the COVID-19 Pandemic National Emergency. If <br /> there was insurance on the damaged property,the name of the insurance company,policy number,claim number,and settled <br /> amount,if any, must becompleted. Copies of the insurance policies in place at the time of disaster,and any correspondence with the <br /> insurance companies on or after March 13,2020, must be attached to the form(Section 4 below). <br /> Under the Everett CARES Small Business Grant Program|make the following statementsstatements�hat a are true, <br /> � <br /> ' l.| hereby state that|am the owner of[enter legal business name 8k oBA] sumnxoFmm/�onmo�uonDexnomashxaB,m�_ � <br /> � ' <br /> i (the^ApFoumnt )andomdulyauthorizedbydheApp|icanttomakechecmrdficationyoomainedinthisReport|ngFormon <br /> � behalf uf the Applicant. <br /> ]. | hereby state and certify to the City of Everett as follows(please check ONE and fill inWmnk): � <br /> ` [�) On ec000mic��um\ businessintenupdonoranyotherWndofimpactre�tedto � <br /> � -- {�ohnkoFmmi�Corpo��unD8ARomash�o8hde| � <br /> COV|D-18VVASexper{encedby[enter legal business name 0kmBA0 ` <br /> � - � <br /> ' F7 On any date on or after March 13, 2020,economic injury,business interruption or any other kind of impact related to � <br /> � [Ov|o'19 WAS NOT experienced by[enter legal business name&DBA] � <br /> m�» EVEF0ETT Everett CARES Small Business Grant Program | Round s | page <br /> m�u W^^".°c,"" <br />