ChildStrive 4/5/2022 - Laserfiche WebLink

Exhibit D: Duplication of Benefits Reporting Form The Duplication of Benefits (DOB) Reporting form is used to assist the City of Everett in administering the American Rescue Plan Act to subrecipients. Forms will help to verify all funding a subrecipient 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 funds, please do not list them below. Source of Funds#1 Lender/Grant Provider Name WSDA Food Assistance Flexible Funding Grants Program Purpose l Food Assistance Flexible Funding Grants Program Amount ;$32,500 ❑Government Loan a Government Grant ❑Government Forgivable Loan ❑ Nonprofit Grant ❑Nonprofit Loan ❑Nonprofit Forgivable Loan ❑Private Loan ❑Other: Source of Funds#2 Lender/Grant Provider Name Purpose Amount ❑Government Loan 0 Government Grant ❑Government Forgivable Loan ❑ Nonprofit Grant ❑Nonprofit Loan ❑Nonprofit Forgivable Loan ❑Private Loan ❑Other: Source of Funds#3 Lender/Grant Provider Name Purpose Amount ❑Government Loan 0 Government Grant ❑Government Forgivable Loan ❑ Nonprofit Grant ❑Nonprofit Loan ❑Nonprofit Forgivable Loan ❑Private Loan ❑Other: Source of Funds#4 Lender/Grant Provider Name Purpose Amount ❑Government Loan 0 Government Grant ❑Government Forgivable Loan 0 Nonprofit Grant ❑Nonprofit Loan ❑Nonprofit Forgivable Loan ❑Private Loan ❑Other: EVE R E T T Everett Forward Grant Program Subrecipient Agreement Page 16 1.1111111 WASHINGTON