Agenda Packet_2022-12-06 - Laserfiche WebLink

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DocuSign Envelope ID: 39D3416E-E2CB-4407-9A82-AOF316B701C9 CALIFORNIA STATE LIBRARY California Library Services Act FINANCIAL CLAIM PAYMENT IN FULL Grant Award #: ZIP22-68 Date: Invoice #: ZIP22-68-01 PO #: Payee Name: Santa Ana Public Library (Legal name of authorized agency to receive, disburse and account for funds*) Complete Address: Street Address, City, State, Zip Code (Warrant will be mailed to this address) Amount Claimed: $9,928.00 Type of Payment: Payable Upon Execution of Agreement ❑ PROGRESS Grantee Name: Santa Ana Public Library ❑ FINAL (Name on Award Letter and Agreement) ❑x IN FULL Project Title: Zip Books Project ❑ AUGMENT For Period From: upon execution to end of grant period CERTIFICATION I hereby certify under penalty of perjury: that I am the duly authorized representative of the claimant herein; that this claim is in all respects true, correct and in accordance with law and the terms of the agreement; and that payment has not previously been received for the amount claimed herein. (Signature of the Authorized Representative) Brian Sternberg (Print Name) (Title) *Legal payee name must match the payee's federal tax return. Warrant will be made payable to payee name. Payee discrepancies in name and/or address may cause delay in payment. If you need to change payee name and/or address, please contact Fiscal Services at stategrants.fiscal(a�library.ca.gov. If you are not using DocuSign electronic signature to submit your claim, please complete the following: MAIL ONE ORIGINAL SIGNATURE TO: EMAIL A SCANNED COPY: California State Library stategrants.fiscal(a-)library.ca.gov Fiscal Office —State Grants PO Box 942837 Sacramento, CA 94237-0001 State of California, State Library Fiscal Office ENY: 2022 PURCHASING AUTHORITY NUMBER: CSL-6120 COA: 5432000 By ITEM NO: 6120-211-0001, Chapter 43, Statutes of 2022 REPORTING STRUCTURE: 61202000 PROGRAM #: 5312 Date (St t I ryUoresen a Ive) 11 — 33 12/6/2022