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PART 2. INSURANCE <br /> Insurance assistance received for COVID-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 CDVID-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 /> n Under the Everett CARES Small Business Grant Program I make the following statements that are true: <br /> tti <br /> 1. I hereby state that I am the owner of[enter legal business name&DBA] .'Y1vLiij {' Yttr ' �� yt.,i�rl. <br /> i (the"Applicant")and am duly authorized by the Applicant to make the certifications contained in this keporting Form on <br /> behalf of the Applicant. itig601114-siy..., <br /> i 2. I hereby state and certify to the City of Everett as follows(please check ONE and fill in blank): of bid" I <br /> i. E1 On any date on or after March 13,2020,economic injury, business i terrc ption or any other ind of imps related to <br /> C COVID-19 WAS experienced by[enter legal business name&DBA]NV^,r'I ryl,.a�M'e' j li,t1L / j 1L, <br /> ! e d <br /> -4-44,411- <br /> 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 NOT experienced by[enter legal business name&DBA] <br /> 4 <br /> mil am <br /> EVERETT <br /> wRs����r�, Everett CARES Small Business Grant Program Round 3 page 8 <br />