Laserfiche WebLink
*:I:I1-3Ya <br />California State Library Grant Agreement & Certification of Compliance <br />Fiscal Office The Knowledge Mobile "Know-Mo": Bringing Mobile Library Services Back to Santa Ana <br />PO Box 942837 Santa Ana Public Library, Invoice# SVBT-026-001 <br />Sacramento, CA 94237-0001 Section 5: Claim for Payment, Page 1 of 1 <br />FINANCIAL CLAIM <br />FIRST PAYMENT <br />ENY: 2019 <br />ITEM NO: 6120-217-0001, Chapter 23, Statutes of 2019 <br />PURCHASING AUTHORITY NUMBER: CSL-6120 <br />REPORTING STRUCTURE: 61202000 <br />COA: 5432000 <br />PROGRAM #: 5312 <br />SCHEDULE NO: <br />SCHEDULE DATE: Date: <br />Claim of: Santa Ana Public Library <br />Address: <br />Amount Claimed: $72,000 Grant Award Number:SVBT-026 <br />For Period From: upon execution to end of grant period <br />Type of Payment PROGRESS FINAL IN FULL <br />Payable Upon Execution of Agreement <br />-------------------------------------------------------------------------------------------------------------------------------- <br />CERTIFICATION <br />I hereby certify under penalty of perjury: that I am the duly authorized <br />representative of the claimant herein; that this claim is in all respects true, <br />correct and in accordance with law and the terms of the agreement; and that <br />payment has not previously been received for the amount claimed herein. <br />0 <br />State of California, State Library Fiscal Office <br />by <br />(State Library Representative) <br />(Signature of the authorized representative) <br />Date <br />MAIL ONE ORIGINAL SIGNATURE TO: <br />California State Library <br />Fiscal Office — Local Assistance <br />State Funded Programs <br />PO Box 942837 <br />Sacramento, CA 94237-0001 <br />(Print name) <br />(Title) <br />-15 <br />