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P C 'NT 1(1 rsi ri v.' E TS Pi F D "T F P <br /> Please enter business name and address <br /> Business legal name: 0 , ext. i LLL <br /> DBA: elkA-cfr-cr cu, oue <br /> Business street address: kif SlAA � <br /> City,state,zip: .� / g <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 Staftold ct Section 1 on li att r pfper-100i s. <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 /> 1. <br /> ) 0 <br /> 2. <br /> 3. <br /> 4. <br /> S. <br /> LEVERETT Everett CARES Small Business Grant Program Round 3 page 7 <br /> WASHINGTON <br />