_____ Period of Affordability of HOME Activity _____ Number of years services will be provided to above HOME activity ___________________________________________(HOME Grantee) certifies that the following services WERE/SHALL BE provided (during the Period of Affordability) to the above HOME Activity. Service Provider Service Provided # Hours of Normal Date(s) TOTAL Match and Funding (brief description) Service Rate Service claimed PER Source(s) Provided per Provided YEAR $ PER Hour $ (including YEAR YEAR) Copy and attach additional pages as needed. Reviewed by: Date: ________________________________________ ___________________________ (Signature of Grantee staff reviewing match claimed) Instructions: Obtain written agreement with agency providing services during of ‘Period Affordability.’ File copy of written agreement with agency in local activity file. Complete Match Certification Form File copy of Form in local activity file Attach original signed form with Activity Completion Report and submit to DOA per normal procedures.
_____ Period of Affordability of HOME Activity _____ Number of years services will be provided to above HOME activity ___________________________________________(HOME Grantee) certifies that the following services WERE/SHALL BE provided (during the Period of Affordability) to the above HOME Activity. Service Provider and Funding Source(s) Service Provided (brief description) # Hours of Service Provided PER YEAR Normal Rate per Hour $ Date(s) Service Provided (including YEAR) TOTAL Match claimed PER YEAR $ Copy and attach additional pages as needed. Reviewed by: Date: ________________________________________ ___________________________ (Signature of Grantee staff reviewing match claimed) Instructions: Obtain written agreement with agency providing services during ‘Period of Affordability.’ File copy of written agreement with agency in local activity file. Complete Match Certification Form File copy of Form in local activity file Attach original signed form with Activity Completion Report and submit to DOA per normal procedures.
hhr-ch6-%20matching%20funds.docx