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Exhibit C Local Match Local Match Certification I,IA Flo"", .. S.ni ... Acimll'lislndlon (This form must be submitted with final contract biUing .) 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 federal 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 SIGNATU RE DATE TITLE OR POSITION PRINTED NAME OF AUTHORIZED REPRESENTATIVE TELEPHONE NUMBER Instructions Name: Printed name of tt1e local entity's agent authorized to complete certification form. Type and source of funds: The type and sour~ of local funds used. In-krn d sources need specific identification showing who danated the item(s) (e.g., volunteers, build ing use, etc.). Dollar amount: Dollars that Were used to match fede ral funds paid during the time period. Dollars reported must agree with amount on the flnal billing . Time frame: Period of time the services were provided. Type of service/contact: Services eligible for FFP. Name of entity: Name of local 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