Common use of Volunteer Services Clause in Contracts

Volunteer Services. 50 Other In-Home Services (Enter Title) .50 Other In-Home Services (Enter Title) 555 .60 NUTRITION SERVICES .00 Xxxxxxxxxx Meals .63 Nutrition Education and Outreach .64 Home Delivered Meals .65 Shopping Assistance .66 Registered Dietician .67 Senior Farmers Mrkt (SFMNP) Food/Checks 555 .70-.80 SOCIAL & HEALTH SERVICES .71 Adult Day Health Services .72 Geriatric Health Screening .73 Medication Management .74 Senior Drug Education .75 Disease Prevention/Health Promotion .76 Elder Abuse Prevention .77 Mental Health .78 Kinship Care .78.1 Kinship Caregivers Support Program .78.1a Service Delivery .78.1b Goods and Services .78.2 Kinship Navigator Services .79 Family Caregiver Support Program .79.1 Information Services .79.2a Access Assistance .79.2b Support Services .79.3 Respite care Services .79.4 Supplemental Services .79.5 Services to Grandparents .79.5a Information Services .79.5b Access Assistance .79.5c Support Services .79.5d Respite Care Services .79.5e Supplemental Services .83 Senior Community Service Employment (SCSEP) .83.1 Program/EWFB .83.2 Program/Other .84 Health Appliance/Limited Health Care .88 Long Term Care Ombudsman .89 Newsletters 555 .90 OTHER ACTIVITIES Disaster Relief Foot Care Peer Counseling Outreach Other (Enter Title) Other (Enter Title) Other (Enter Title) Other (Enter Title) Other (Enter Title) Total Services GRAND TOTAL Revenue Total This amendment change: Current award this amendment Prior amendment awarded Net Change Funds Match Certification Exhibit C (This form must be submitted with final contract billing.) I, certify that local funds and/or in-kind items PRINT NAME TYPE AND SOURCE OF PRIVATE / LOCAL FUNDS / ITEMS were provided in the amount of $ TYPE AND SOURCE OF NON-PROFIT FUNDS / ITEMS were provided in the amount of $ TYPE AND SOURCE OF FEDERAL FUNDS / ITEMS were provided in the amount of $ and were used to match funds paid during the time period of through for . TYPE OF SERVICE/CONTRACT 5 NAME OF ENTITY NAME OF AUTHORIZED AGENT CONTRACT / VENDOR NUMBER AUTHORIZED REPRESENTATIVE’S SIGNATURE DATE TITLE OR POSITION PRINTED NAME OF AUTHORIZED REPRESENTATIVE TELEPHONE NUMBER Instructions Name: Printed name of the entity’s agent authorized to complete certification form. Type and source of funds: The type and source of funds used. Please break out different types of funding sources. Not all funding sources will be necessary to complete each certification. In-kind sources need specific identification showing who donated the item(s) (e.g., volunteers, building use, etc.).

Volunteer Services. 50 Other In-Home Services (Enter Title) .50 Other In-Home Services (Enter Title) 555 .60 NUTRITION SERVICES .00 Xxxxxxxxxx .61 Congregate Meals .63 Nutrition Education and Outreach .64 Home Delivered Meals .65 Shopping Assistance .66 Registered Dietician .67 Senior Farmers Mrkt (SFMNP) Food/Checks 555 .70-.80 SOCIAL & HEALTH SERVICES .71 Adult Day Health Services .72 Geriatric Health Screening .73 Medication Management .74 Senior Drug Education .75 Disease Prevention/Health Promotion .76 Elder Abuse Prevention .77 Mental Health .78 Kinship Care .78.1 Kinship Caregivers Support Program .78.1a Service Delivery .78.1b Goods and Services .78.2 Kinship Navigator Services .79 Family Caregiver Support Program .79.1 Information Services .79.2a Access Assistance .79.2b Support Services .79.3 Respite care Services .79.4 Supplemental Services .79.5 Services to Grandparents .79.5a Information Services .79.5b Access Assistance .79.5c Support Services .79.5d Respite Care Services .79.5e Supplemental Services .83 Senior Community Service Employment (SCSEP) .83.1 Program/EWFB .83.2 Program/Other .84 Health Appliance/Limited Health Care .88 Long Term Care Ombudsman .89 Newsletters 555 .90 OTHER ACTIVITIES Disaster Relief Foot Care Peer Counseling Outreach Other (Enter Title) Other (Enter Title) Consolidated Approp. Act Home Delivered Meals CFDA 93.045 Consolidated Approp. Act Expand Access to Vaccines CFDA 93.044 Other (Enter Title) Other (Enter Title) Other (Enter Title) Total Services GRAND TOTAL Revenue Total To be completed by XXXXX This amendment change: Current award this amendment Prior amendment awarded Net Change Funds Match Certification Exhibit C STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES‌ Aging and Long-Term Support Administration Home and Community Services Division‌ PO Box 45600, Olympia, WA 98504-5600 HCS MANAGEMENT BULLETIN H21-025 – Policy & Procedure April 02, 2021 TO: Area Agency on Aging Directors FROM: Xxx Xxxxxx, Director, Home and Community Services Division Xxxxx Xx, Director, Management Services Division SUBJECT: Consolidated Appropriations Act, Supplemental Funding Title III-C2 PURPOSE: To notify Area Agencies on Aging (This form must be submitted with final contract billingAAAs) of their Consolidated Appropriations Act funding and provide information on funding details, billing and reporting requirements.) I, certify that local funds and/or in-kind items PRINT NAME TYPE AND SOURCE OF PRIVATE / LOCAL FUNDS / ITEMS were provided in the amount of $ TYPE AND SOURCE OF NON-PROFIT FUNDS / ITEMS were provided in the amount of $ TYPE AND SOURCE OF FEDERAL FUNDS / ITEMS were provided in the amount of $ and were used to match funds paid during the time period of through for . TYPE OF SERVICE/CONTRACT 5 NAME OF ENTITY NAME OF AUTHORIZED AGENT CONTRACT / VENDOR NUMBER AUTHORIZED REPRESENTATIVE’S SIGNATURE DATE TITLE OR POSITION PRINTED NAME OF AUTHORIZED REPRESENTATIVE TELEPHONE NUMBER Instructions Name: Printed name of the entity’s agent authorized to complete certification form. Type and source of funds: The type and source of funds used. Please break out different types of funding sources. Not all funding sources will be necessary to complete each certification. In-kind sources need specific identification showing who donated the item(s) (e.g., volunteers, building use, etc.).

Volunteer Services. 50 Other In-Home Services (Enter Title) .50 Other In-Home Services (Enter Title) 555 .60 NUTRITION SERVICES .00 Xxxxxxxxxx .61 Congregate Meals .63 Nutrition Education and Outreach .64 Home Delivered Meals .65 Shopping Assistance .66 Registered Dietician .67 Senior Farmers Mrkt (SFMNP) Food/Checks 555 .70-.80 SOCIAL & HEALTH SERVICES .71 Adult Day Health Services .72 Geriatric Health Screening .73 Medication Management .74 Senior Drug Education .75 Disease Prevention/Health Promotion .76 Elder Abuse Prevention .77 Mental Health .78 Kinship Care .78.1 Kinship Caregivers Support Program .78.1a Service Delivery .78.1b Goods and Services .78.2 Kinship Navigator Services .79 Family Caregiver Support Program .79.1 Information Services .79.2a Access Assistance .79.2b Support Services .79.3 Respite care Services .79.4 Supplemental Services .79.5 Services to Grandparents .79.5a Information Services .79.5b Access Assistance .79.5c Support Services .79.5d Respite Care Services .79.5e Supplemental Services .83 Senior Community Service Employment (SCSEP) .83.1 Program/EWFB .83.2 Program/Other .84 Health Appliance/Limited Health Care .88 Long Term Care Ombudsman .89 Newsletters 555 .90 OTHER ACTIVITIES Disaster Relief Foot Care Peer Counseling Outreach Other (Enter Title) Other (Enter Title) Other (Enter Title) Other (Enter Title) Other (Enter Title) Total Services GRAND TOTAL Revenue Total To be completed by XXXXX This amendment change: Current award this amendment Prior amendment awarded Net Change Funds Match Certification Exhibit C (This form must be submitted with final contract billing.) I, certify that local funds and/or in-kind items PRINT NAME TYPE AND SOURCE OF PRIVATE / LOCAL FUNDS / ITEMS were provided in the amount of $ TYPE AND SOURCE OF NON-PROFIT FUNDS / ITEMS were provided in the amount of $ TYPE AND SOURCE OF FEDERAL FUNDS / ITEMS were provided in the amount of $ and were used to match funds paid during the time period of through for . TYPE OF SERVICE/CONTRACT 5 NAME OF ENTITY NAME OF AUTHORIZED AGENT CONTRACT / VENDOR NUMBER AUTHORIZED REPRESENTATIVE’S SIGNATURE DATE TITLE OR POSITION PRINTED NAME OF AUTHORIZED REPRESENTATIVE TELEPHONE NUMBER Instructions Name: Printed name of the entity’s agent authorized to complete certification form. Type and source of funds: The type and source of funds used. Please break out different types of funding sources. Not all funding sources will be necessary to complete each certification. In-kind sources need specific identification showing who donated the item(s) (e.g., volunteers, building use, etc.).

Volunteer Services. 50 Other In-Home Services (Enter TitleMental Health) .50 Other In-Home Services (Enter Title) 555 .60 NUTRITION SERVICES .00 Xxxxxxxxxx Uncompensated Contractor Costs - MCS .61 Congregate Meals .63 Nutrition Education and Outreach .64 Home Delivered Meals .65 Shopping Assistance .66 Registered Dietician .67 Senior Farmers Mrkt (SFMNP) Food/Checks $33,467 volunteer labor; $34,350 project income - BSA/S'Klallam Tribe Volunteer labor - Bremerton Services Association (BSA)$40,236 volunteer labor; $80,150 project income - BSA 555 .70-.80 SOCIAL & HEALTH SERVICES .71 Adult Day Health Services .72 Geriatric Health Screening .73 Medication Management .74 Senior Drug Education .75 Disease Prevention/Health Promotion .76 Elder Abuse Prevention .77 Mental Health .78 Kinship Care .78.1 Kinship Caregivers Support Program .78.1a Service Delivery .78.1b Goods and Services .78.2 Kinship Navigator Services .79 Family Caregiver Support Program .79.1 Information Services .79.2a Access Assistance .79.2b Support Services .79.3 Respite care Services .79.4 Supplemental Services .79.5 Services to Grandparents .79.5a Information Services .79.5b Access Assistance .79.5c Support Services .79.5d Respite Care Services .79.5e Supplemental Services .83 Senior Community Service Employment (SCSEP) SCSEP .83.1 Program/EWFB .83.2 Program/Other .84 Health Appliance/Limited Health Care .88 Long Term Care Ombudsman .89 Newsletters 555 .90 OTHER ACTIVITIES Disaster Relief Foot Care Peer Counseling Outreach Other Powerful Tools Training (Enter TitleMCS) Other (Enter Title) Other (Enter Title) Other (Enter Title) Other (Enter Title) Total and sbusequent workshops Title 3-E Information matched with SFCSP fundsTitle 3-E Access Assistance matched with SFCSP funds Title 3-E Support Services GRAND TOTAL Revenue Total This amendment change: Current award this amendment Prior amendment awarded Net Change Funds Match Certification Exhibit C (This form must be submitted matched with final contract billing.) I, certify that local SFCSP funds and/or in-kind items PRINT NAME TYPE AND SOURCE OF PRIVATE / LOCAL FUNDS / ITEMS were provided in the amount of $ TYPE AND SOURCE OF NON-PROFIT FUNDS / ITEMS were provided in the amount of $ TYPE AND SOURCE OF FEDERAL FUNDS / ITEMS were provided in the amount of $ and were used to match funds paid during the time period of through for . TYPE OF SERVICE/CONTRACT 5 NAME OF ENTITY NAME OF AUTHORIZED AGENT CONTRACT / VENDOR NUMBER AUTHORIZED REPRESENTATIVE’S SIGNATURE DATE TITLE OR POSITION PRINTED NAME OF AUTHORIZED REPRESENTATIVE TELEPHONE NUMBER Instructions Name: Printed name of the entity’s agent authorized to complete certification form. Type and source of funds: The type and source of funds used. Please break out different types of funding sources. Not all funding sources will be necessary to complete each certification. In-kind sources need specific identification showing who donated the item(s) (e.g., volunteers, building use, etc.).SFCSP Respite BSA - Volunteer Labor

Volunteer Services. 50 Other In-Home Services (Enter TitleMental Health) .50 Other In-Home Services (Enter Title) 555 .60 NUTRITION SERVICES .00 Xxxxxxxxxx .61 Congregate Meals $56,055 volunteer labor; $28,000 project income (BSA/S'Klallam Tribe) .63 Nutrition Education and Outreach Volunteer labor - Bremerton Services Association (BSA) .64 Home Delivered Meals $26,932 volunteer labor; $50,000 project income (BSA) .65 Shopping Assistance .66 Registered Dietician .67 Senior Farmers Mrkt (SFMNP) Food/Checks 555 .70-.80 SOCIAL & HEALTH SERVICES .71 Adult Day Health Services .72 Geriatric Health Screening .73 Medication Management .74 Senior Drug Education .75 Disease Prevention/Health Promotion .76 Elder Abuse Prevention .77 Mental Health Evidenced based program - MCS Counseling .78 Kinship Care .78.1 Kinship Caregivers Support Program .78.1a Service Delivery .78.1b Goods and Services .78.2 Kinship Navigator Services .79 Family Caregiver Support Program .79.1 Information Services .79.2a Access Assistance .79.2b Support Services Uncompensated contractor costs - MCS Counseling .79.3 Respite care Services .79.4 Supplemental Services Pro-Xxxx services .79.5 Services to Grandparents .79.5a Information Services .79.5b Access Assistance .79.5c Support Services .79.5d Respite Care Services .79.5e Supplemental Services .83 Senior Community Service Employment (SCSEP) .83.1 Program/EWFB .83.2 Program/Other .84 Health Appliance/Limited Health Care .88 Long Term Care Ombudsman .89 Newsletters 555 .90 OTHER ACTIVITIES Disaster Relief Foot Care Peer Counseling Outreach Other (Enter Title) Other (Enter Title) Other (Enter Title) Other (Enter Title) Other (Enter Title) Total Services GRAND TOTAL Revenue Total This amendment change: Current award this amendment Prior amendment awarded Net Change Funds Match Certification Exhibit C (This form must be submitted with final contract billing.) I, certify that local funds and/or in-kind items PRINT NAME TYPE AND SOURCE OF PRIVATE / LOCAL FUNDS / ITEMS were provided in the amount of $ TYPE AND SOURCE OF NON-PROFIT FUNDS / ITEMS were provided in the amount of $ TYPE AND SOURCE OF FEDERAL FUNDS / ITEMS were provided in the amount of $ and were used to match funds paid during the time period of through for . TYPE OF SERVICE/CONTRACT 5 NAME OF ENTITY NAME OF AUTHORIZED AGENT CONTRACT / VENDOR NUMBER AUTHORIZED REPRESENTATIVE’S SIGNATURE DATE TITLE OR POSITION PRINTED NAME OF AUTHORIZED REPRESENTATIVE TELEPHONE NUMBER Instructions Name: Printed name of the entity’s agent authorized to complete certification form. Type and source of funds: The type and source of funds used. Please break out different types of funding sources. Not all funding sources will be necessary to complete each certification. In-kind sources need specific identification showing who donated the item(s) (e.g., volunteers, building use, etc.).Services