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Exhibit C <br />Funds Match Certification <br />(This form must be submitted with final contract billing.) <br />PRINT NAME <br />TYPE AND SOURCE OF PRIVATE / LOCAL FUNDS / ITEMS <br />TYPE AND SOURCE OF NON-PROFIT FUNDS / ITEMS <br />TYPE AND SOURCE OF FEDERAL FUNDS / ITEMS <br />and were used to match funds paid during the time period of <br />TYPE OF SERVICE/CONTRACT <br />c edify that local funds and/or in-kind items <br />- were provided in the amount of <br />- were provided in the amount of $ <br />_ were provided in the amount of $ <br />_.. through <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 />for <br />Name: <br />Printed name of the entity's agent authorized to complete certification form. <br />Type and source of funds: <br />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: <br />Dollars that were used to match funds paid during the time period. Dollars reported m ust <br />agree with amount on the final billing. <br />Time frame: <br />Period of time the services were provided. <br />Type of service/Contract: <br />Services eligible for matching. <br />Name of entity: <br />Name of entity that is providing the funding match. <br />Name of authorized agent: <br />Name of agent, if different than "name of entity" above, that is authorized to act on behalf of <br />entity. <br />Contract/vendor number: <br />The contractor vendor number of the entity. <br />Authorized representative's signature: <br />The signature of the entity authorized representative. <br />Date: <br />Date when form was completed. <br />Title or position: <br />Title or position of entity authorized representative <br />Printed name: <br />Printed name of authorized representative. <br />Telephone number: <br />Telephone number of authorized representative. Include the area code <br />DSHS Central Contract Services <br />Page 21 <br />1769CS County Agreement 6-15-2017 <br />