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acpailmear of �,xlar <br />a ]]ralrh sercires <br />FSA pinmMlnl sewkuf <br />AdminisUn6un <br />PRINT NAME <br />Exhibit C <br />Local Match <br />Local Match Certification <br />(This form must be submitted with final contract billing.) <br />certify that local funds and/or in-kind items <br />_... were provided in the amount of <br />TYPE AND SOURCE OF FUNDSIITEMS <br />$_ and were used to match federal funds paid during the time period <br />of _ through for <br />NAME O <br />NAME OF AUTHORIZED AGENT <br />VE'S S <br />TYPE OF SERVICEICONTRACT <br />Instructions <br />OR POSITION <br />1►L9LTVCIV <br />NUMBER <br />Name: Printed name of the local entity's agent authorized to complete certification form. <br />Type and source of funds: The type and source of local funds used. In-kind sources need specific identification <br />showing who donated the item(s) (e.g., volunteers, building use, etc,). <br />Dollar amount: Dollars that were used to match federal funds paid during the time period. Dollars <br />reported must agree with amount on the final billing. <br />Time frame: Period of time the services were provided. <br />Type of service/contact: Services eligible for FFP. <br />Name of entity: Name of local entity that is providing the local funding match. <br />Name of authorized agent: Name of local entity that is authorized to act in behalf of local entity, <br />Contract/vendor number: The contract or vendor number of the local entity. <br />Authorized representative's signature: The signature of the local entity authorized representative, <br />Date: Date when form was completed. <br />Title or position: Title or position of local entity authorized representative <br />Printed name: Printed name of authorized representative. <br />Telephone number: Telephone number of authorized representative. include the area code. <br />Page 23 <br />DSHS Central Contract Services <br />1769CS Counly Agreement 7-14-2015 <br />