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<br /> IREPORTIr•Jci
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<br /> Please enter business name and address
<br /> s Business legal name: 6u zz Z,vN, G,
<br /> DBA:
<br /> Business street address: 9 9/
<br /> City,state,zip;
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<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").
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<br /> Programs Business has applied to AND received funds from:
<br /> 1.
<br /> 2.
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<br /> 4.
<br /> 5.
<br /> E V E R E T T Everett CARES Small Business Grant Program Round 3 page 7
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