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Everett Forward Grant Program | Subrecipient Agreement | Page 16 <br />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 /> <br />Source of Funds #1 <br />Lender/Grant Provider Name <br />Purpose <br />Amount <br />Government Loan 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 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 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 Government Grant Government Forgivable Loan <br /> Nonprofit Grant Nonprofit Loan Nonprofit Forgivable Loan <br />Private Loan Other: