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DocuSign Envelope ID:AC632329-6A2C-41CA-B8AA-8D15BC504B89 <br /> PART 2. INSURANCE <br /> Insurance assistance received for COVlD-19 Pandemic National Emergency related losses. Insurance company information must be <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 be completed. 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 I make the following statements that are true: <br /> 1. I hereby state that I am the owner of[enter legal business name&DBA] <br /> (the"Applicant")and am duly authorized by the Applicant to make the certifications contained in this Reporting Form on <br /> behalf of the Applicant. <br /> ( 2. I hereby state and certify to the City of Everett as follows(please check ONE and fill in blank): <br /> n On any date on or after March 13,2020,economic injury, business interruption or any other kind of impact related to <br /> COVID-19 WAS experienced by[enter legal business name&DBA] <br /> On anydate on or after March 13,2020,economic injury,business interruption or anyother kind of impact related to <br /> ❑ p p <br /> COVID-19 WAS NOT experienced by[enter legal business name&DBA] <br /> EVE R E T T Everett CARES Small Business Grant Program Round 3 page 8 <br />