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2020 CDBG-CV Agreement Exhibit C City of Everett Community Development Block Grant Program CARES Funds (CDBG-CV) Duplication of Benefits Reporting Form The Duplication of Benefits (DOB) Reporting form is used to assist the City of Everett in administering the Community Development Block Grant-CV to subrecipients. Forms will help to verify all funding an agency has received for COVID-19 Pandemic National Emergency in order to eliminate any duplication of benefits. You should only report on the information related to the program supported by this agreement. Instructions: Identify below all sources of active federal, state, or other public fund awards that the agency has received as a result of the COVID-19 Pandemic National Emergency to support the program within this agreement. If you received COVID-19 funds and they do not support the program receiving City of Everett CDBG-CV funds, please do not list them below. Source of Funds#1 Lender/Grant Provider Name Click or tap here to enter text. Purpose Click or tap here to enter text. Amount Click or tap here to enter text. ❑Government Loan ❑ Government Grant ❑Government Forgivable Loan ❑ Nonprofit Grant ❑Nonprofit Loan ❑Nonprofit Forgivable Loan El Private Loan ❑Other:Click or tap here to enter text. Source of Funds#2 Lender/Grant Provider Name Click or tap here to enter text. Purpose Click or tap here to enter text. Amount Click or tap here to enter text. ❑Government Loan ❑ Government Grant ❑Government Forgivable Loan ❑ Nonprofit Grant ❑Nonprofit Loan ❑Nonprofit Forgivable Loan ❑Private Loan ❑Other: Click or tap here to enter text. Source of Funds#3 Lender/Grant Provider Name Click or tap here to enter text. Purpose Click or tap here to enter text. Amount Click or tap here to enter text. ❑Government Loan ❑ Government Grant ❑Government Forgivable Loan ❑ Nonprofit Grant ❑Nonprofit Loan ❑Nonprofit Forgivable Loan ❑Private Loan ❑Other: Click or tap here to enter text. Duplication of Benefits Reporting Form