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1 fSA Fill ....... s • ...; ... Admj!1i5ltil~lJn Exhibit C Local Match Local Match Certification (This form must be submitted with final contract billing .) I-=~~,..,...",::--_____________ certify that local funds and/or in-kind items PRINT NAME ~~..,..,..,.,~~=--="'",...".~~~=:-:-:::-_______________ were provided in the amount of TYPE AND SOURCE OF FUNDSIITEMS $ ___________ and were used to match federar funds paid during the time period of __________ through ___________ for TYPE OF SERVICE/CONTRACT ~~ NAME OF ENTITY NAME OF AUTHORIZED AGENT I CONTRACTNENOOR NUMBER AUTHORIZED REPRESENTATIVE'S SIGNATURE DATE TITLE OR POSITION PRINTED NAME OF AUTHORIZED REPRESENTATIVE TELEPHONE NUMBER Instructions Name: Printed name of the local entity's agent authorized to complete certification form. Type and source of funds: The type and source of local funds used. 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 federal funds paid during the time period. Dollars reported must agree with amount on the final billing. Time frame: Period of time the services were provided. Type of service/contact: Services eligible for FFP. Name of entity : Name of locar entity that is providing the local funding match. Name of authorized agent: Name of local entity that is authorized to act in behalf of local entity. Contract/vendor number: The contract or vendor number of the local entity. Authorized representative's signature: The signature of the local entity authorized representative. Date: Date when form was completed. Title or position: Title or position of local entity authorized representative Printed name: Printed name of authorized representative. Telephone number: Telephone number of authorized representative. Include the area code. DSHS Central Contract Services 1769CS County Agreement 7-14-2015 Page 23