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4ti <br /> k7 <br /> 1s, c. ! a 11 ,4 ' 4"' <br /> (44'" .501,4.84- 544 <br /> Please enter business name and address o ( 0161 /he, 4 {/o ` O <br /> Business legal name: , ,fir-- l ., (-41V I t jt(L-t:y <br /> DBA: krnb*r 1 �_ Dui 6 <br /> Business street address: 1 �[Al . <br /> City,state,zip: \-kart: j lb <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.w31?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 /> 1. t) 64, Lterieynp to\roN,4- Acjiji� (p,firi‘ Mat\ Jv ZZo <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> `. EVE R E TT Everett CARES Small Business Grant Program Round 3 page 7 <br /> WASHINGTON <br />