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Exhibit D: Duplication of Benefits Reporting Formnp fi <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 /> ['Government Loan 0 Government Grant ❑Government Forgivable Loan <br /> ❑Nonprofit Grant ❑Nonprofit Loan ❑Nonprofit Forgivable Loan <br /> ❑Private Loan ❑Other: <br /> Source of Funds#2 <br /> 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 ❑Nonprofit Forgivable Loan <br /> ❑Private Loan ❑Other: <br /> Source of Funds#4 <br /> 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 /> iEVERETT Everett Forward Grant Program Subrecipient Agreement i Page 16 <br /> imm WASHINGTON <br />