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ExhibitC local Match Local Match Certification I FSA ~ih.uclol S.I\'k ... Admjnj!lll"~LJn (This form must be submitted with final contract billing.) =-: 1,-=-::--:-::=-=-"",.....,...,.,:-_____________ certify that local funds and/or In-kind items PRINT NAME =:-:=-=-,.,.,..",~~~-=~_:_:_:='"="".,...,._=__--------------were provided in the amount of TYPE AND SOURCE OF FUND SIITEMS $ ___________ and were used to match federal funds paid during the time period of __________ through ___________ for TYPE OF SERVICE/C O!IITRACT NAME OF ENJITY NAME OF AUTHORIZED AGENT I CONTRACTNENDOR NUMBER AUTHORIZEO REPRESENTAT IV E'S SIG NATURE DATE TITLE OR POSITION PRINTED NAME OF AUTttORI ZED REPRESENTATIVE TEl.EPHON E 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 loca l funds use d. In-k in d 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 repor ted must agree with amoun t 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 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