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Exhibit C Funds Match Certification (This form must be submitted with final contract billing.) PRINT NAME TYPE AND SOURCE OF PRIVATE / LOCAL FUNDS / ITEMS TYPE AND SOURCE OF NON-PROFIT FUNDS / ITEMS TYPE AND SOURCE OF FEDERAL FUNDS / ITEMS and were used to match funds paid during the time period of TYPE OF SERVICE/CONTRACT certify that local funds and/or in-kind items - were provided in the amount of - were provided in the amount of - were provided in the amount of through for NAME OF ENTITY NAME OF AUTHORIZED AGENT CONTRACT/ VENDOR NUMBER AUTHORIZED REPRESENTATIVE'S SIGNATURE DATE TITLE OR POSITION PRINTED NAME OF AUTHORIZED REPRESENTATIVE TELEPHONE NUMBER Contract/vendor number: Authorized representative's signature: Date Title or position: Printed name: The contract or vendor number of the entity. The signature of the entity authorized representative. Date when form was completed. Title or position of entity authorized representative Printed name of authorized representative. Telephone number: Telephone number of authorized representative. Include the area code DSHS Central Contract Services Page 21 1769CS County Agreement 6-15-2017 Instructions Name: Printed name of the entity's agent authorized to complete certification form. Type and source of funds: The type and source of funds used. Please breakout different types of funding sources. Not all funding sources will be necessary to complete each certification. In-kind sources need specific identification showing who donated the item(s) (e.g., volunteers, building use, etc.). Dollar amount: Dollars that were used to match funds paid during the time period. Dollars reported m ust agree with amount on the final billing. Time frame: Period of time the services were provided. Type of service/Contract: Services eligible for matching. Name of entity: Name of entity that is providing the funding match. Name of authorized agent: Name of agent, if different than "name of entity" above, that is authorized to act on behalf of entity. Contract/vendor number: Authorized representative's signature: Date Title or position: Printed name: The contract or vendor number of the entity. The signature of the entity authorized representative. Date when form was completed. Title or position of entity authorized representative Printed name of authorized representative. Telephone number: Telephone number of authorized representative. Include the area code DSHS Central Contract Services Page 21 1769CS County Agreement 6-15-2017