Laserfiche WebLink
Exhibit D: Duplication of Benefits Reporting Form <br /> The Duplication of Benefits (DOB) Reporting form is used to assist the City of Everett in administering the <br /> American Rescue Plan Act to subrecipients. Forms will help to verify all funding a subrecipient has received for <br /> COVID-19 Pandemic National Emergency in order to eliminate any duplication of benefits. You should only report <br /> on the information related to the program supported by this Agreement. <br /> Instructions: <br /> Identify below all sources of active federal, state, or other public fund awards that the agency has received as a <br /> result of the COVID-19 Pandemic National Emergency to support the program within this agreement. If you <br /> received COVID-19 funds and they do not support the program receiving City of Everett funds, please do not list <br /> them below. <br /> Source of Funds#1 <br /> Lender/Grant Provider Name <br /> Purpose <br /> Amount <br /> L ❑Gov❑Government Loan 0 Government Grant <br /> ernment Forgivable Loan <br /> ❑ Nonprofit Grant ❑Nonprofit Loan ❑Nonprofit Forgivable Loan <br /> ❑Private Loan ❑Other: <br /> Source of Funds#2 <br /> i Lender/Grant Provider Name <br /> Purpose <br /> Amount <br /> ❑Government Loan 0 Government Grant ❑Government Forgivable Loan <br /> ❑ Nonprofit Grant ❑Nonprofit Loan ❑Nonprofit Forgivable Loan <br /> ❑Private Loan ❑Other: <br /> Source of Funds#3 <br /> Lender/Grant Provider Name <br /> Purpose <br /> Amount <br /> ❑Government Loan 0 Government Grant ❑Government Forgivable Loan <br /> ❑ Nonprofit Grant ❑Nonprofit Loan ONonprofit Forgivable Loan <br /> ❑Private Loan ❑Other: <br /> Source of Funds#4 <br /> I Lender/Grant Provider Name <br /> Purpose <br /> Amount <br /> ❑Government Loan 0 Government Grant ❑Government Forgivable Loan <br /> ❑Nonprofit Grant ❑Nonprofit Loan ❑Nonprofit Forgivable Loan <br /> ❑Private Loan ❑Other: <br /> EVE R E T Taz <br /> Everett Forward Grant Program I Subrecipient Agreement i Page 16 <br /> WASHINGTON <br />