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<br />EXHIBIT C <br /> <br />ll!lllilllli1111111111Illllll'iliIIlTAlliiiDIl..6Y.llliliiillllllllll'!:'II'II!III'I!!Jl!l'l <br /> <br />This form must be submitted with copies of bank statements or certified financial reports from the Grantee <br />that verify the account number, date and amount of deposit, interest rates and total interest earned as of the <br />date of this report. <br /> <br />.......... -. <br />............,......... <br />Grii.g~i@> <br /> <br />......................................._... d...._._............... H . . <br />--_._-_...............................--..........-.-.------------ <br />B9pp~irmi.IQm~r}: <br /> <br /> <br />.......................................-.........-.-.....-.......... <br />.:-..-,-.......:.................................:.......................................-.....................'.................-.-.-...---.._..-. <br />im9qlqffJ~P~~I::i:U <br />........................................................... . <br /> <br />............ ................................. .........--......... <br />....-.......-.............................................................-.-.-..-.-. <br />.-.-.-.-.-_....._....-.......................-...........:-................................................-................................ <br />g~p~ij.~~~Hi.~gm~~~) <br /> <br /> <br />.. .....................--.--............-.....--.-...- <br />.-.".d................................................ <br />. - . . - . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br />..-...................................................... <br />...................................................... <br />.............-........................................... <br />.-..................................................... <br />..-...................................................... <br />......................................................... <br />';-II~~:~lil_1~~~~iliilir <br /> <br />.................... ........................................... <br /> <br /> <br />AUTHORIZED SIGNATURE & TITLE <br /> <br />DATE <br /> <br />Building Better Communities <br /> <br />Exhibits - Administrative Rules <br />