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DocuSign Envelope ID: 39D3416E-E2CB-4407-9A62-AOF316B701C9 <br />CALIFORNIA STATE LIBRARY <br />California Library Services Act <br />Grant Award #: <br />Invoice #: <br />Payee Name: <br />Complete Address: <br />Amount Claimed: <br />Grantee Name: <br />Project Title: <br />ZIP22-68 <br />ZIP22-68-01 <br />Santa Ana Public Library <br />FINANCIAL CLAIM <br />PAYMENT IN FULL <br />Date: 11/21/2022 <br />PO #: 5627 <br />(Legal name of authorized agency to receive, disburse and account for funds') <br />26 civic center Plaza, Santa Ana, CA 92701 <br />Street Address, City, State, Zip Code (Warrant will be mailed to this address) <br />$9,928.00 Type of Payment: <br />Payable Upon Execution of Agreement ❑ PROGRESS <br />Santa Ana Public Library ❑ FINAL <br />(Name on Award Letter and Agreement) M IN FULL <br />Zip Books Project ❑ AUGMENT <br />For Period From: upon execution to end of grant period <br />CERTIFICATION <br />I hereby certify under penalty of perjury: that I am the duly authorized representative of the claimant herein; <br />that this claim is in all respects true, correct and in accordance with law and the terms of the agreement; and <br />that payment has not previously been received for the amount claimed herein. <br />DwUSI n0hy: <br />By l�tatn S}tvttiLLrr� <br />(Signature of the Authorized Representative) <br />Brian Sternberg Library Services Director <br />(Print Name) (Title) <br />'Legal payee name must match the payee's federal tax return. Warrant will be made payable to payee name. Payee <br />discrepancies in name and/or address may cause delay in payment. If you need to change payee name and/or address, <br />please contact Fiscal Services at stategrants.fiscal(dlibrary.ca.gov. <br />If you are not using DocuSign electronic signature to submit your claim, please complete the following: <br />EMAIL A SCANNED COPY: <br />stategrants.fisca l(cDlibrary.ca.gov <br />State of California, State Library Fiscal Office <br />ENY: 2022 <br />PURCHASING AUTHORITY NUMBER: CSL-6120 <br />COA: 5432000 <br />MAIL ONE ORIGINAL SIGNATURE TO: <br />California State Library <br />Fiscal Office —State Grants <br />PO Box 942837 <br />Sacramento, CA 94237-0001 <br />ITEM NO: 6120-211-0001, Chapter 43, Statutes of 2022 <br />REPORTING STRUCTURE: 61202000 <br />PROGRAM #: 5312 <br />Imo�, D.- 8i9�edby: <br />By I i"Sutn,ia f AS{tu.OU. Date 11/21/2022 <br />ID3135f385FD493... <br />(State Library Representative) <br />