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