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• <br /> BENEHTS <br /> � O h KLei .. <br /> -9, FUR <br /> yam.........-.....n..:.. ............ ........+....-...-.:, .......... :w-... r,...,..., .:.....:..........n-.........-n.....,i.,.. .v....-..: u e,.r. ..r,...n...a.. nrt.,...w.r.:.,,.,.......,.•.,..r..w.,...,.sn+.. ,......awrw.ww»,<.nw......w.0 ne. r,u.wm.,wnvvrw+.......,a.uw+,nwvauaowwnax,..,v.,,raren ... <br /> Please enter business name and address <br /> Business legal name: . ��' fOOk � It M w\V-(?StelavaUt <br /> DBA• \"7-71 S k Vikt C(k 4r\ \C \S'\ a I ((o 1 k.. k1f"' <br /> Business street address: k' E, �'' ,' me, ` .,# . Tap <br /> City, state,zip: tleMA sk,NYA <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 /> 3 <br /> z. ottv► <br /> 6'C 'elc <br /> 3. <br /> 4. <br /> S. <br /> E VE R E T T Everett CARES Small Business Grant Program Round 3 ' page 7 <br /> WASHINGTON <br />