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1UPLICATION OF BENEFITS REPORTING FORM <br /> Please enter business name and address <br /> Business legal name: Anh T Nguyen <br /> DBA: Angel Hair& Nail <br /> Business street address: 4823 Evergreen Way <br /> City,state,zip: Everett, WA 98203-2830 <br /> DESCRIPTION <br /> The Duplication of Benefits(DOB) Reporting form is used to assist the City of Everett in administering the Everett CARES Small <br /> Business Grant Program.The form will help to verify all funding a business has received for COVID-19 Pandemic National Emergency <br /> related losses in order to eliminate any duplication of benefits. <br /> Receiving funds from other sources does not disqualify you from receiving an 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 documentation/receipt of spending to two different <br /> fund providers will be considered inappropriate"double-dipping." <br /> NOTE:This form requests insurance information(e.g. 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 Pandemic 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 312 on Duplication of Benefits. <br /> Provide the name 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 /> i•PPP Loan from BECU, $18,832.00 <br /> z. EIDL Grant from BECU, $5000.00 <br /> 3. <br /> 4. <br /> I 5. <br /> 1� E VE R E T T Everett CARES Small Business Grant Program Round 3 i page 7 <br /> WASHFNGTON <br />