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• <br /> 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 COVID-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 /> Under the Everett CARES Small Business Grant Program I make the following statements that are true: <br /> 1.I hereby state that I am the owner of[enter legal business name&DBA] r3, &"-- �S <br /> (the"Applicant")and am duly authorized by the Applicant to make the certifications contained in this Reporting Form on p t,C <br /> behalf of the Applicant. f a c _� <br /> 2.I hereby state and certify to the City of Everett as follows(please check ONE and fill in blank): <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 experienced by[enter legal business name&DBA] Q d6cA6c0- T`{Ba�G 0H� Z. S <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 /> • <br /> WVERETT Everett CARES Small Business Grant Pro ramRound 3 WASH INGTON g IounI page 8 <br />