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DocuSign Envelope ID:AC632329-6A2C-4ICA-B8AA-8D15BC504B89 <br /> 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 CDVID-19 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 i <br /> 12/15/2020 <br /> Date <br /> D{cuSigned by: <br /> It] -- Anh Thi Nguyen <br /> •1D547©66S79<FB... <br /> Applicant Signature Print Applicant Name <br /> 00, <br /> 1 <br /> Joint Applicant Signature Print Joint Applicant Name <br /> Continued... <br /> MAT EVE R E T T Everett CARES Small Business Grant Program Round 3 i page 11 <br /> WASNINCTON <br />