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CALIFORNIA STATE LIBRARY FINANCIAL CLAIM <br />California Library Services Act PAYMENT IN FULL <br /> <br /> <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 />By <br /> <br /> <br /> (Signature of the Authorized Representative) <br /> <br /> <br /> <br /> (Print Name) (Title) <br /> <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@library.ca.gov. <br /> <br /> <br />If you are not using DocuSign electronic signature to submit your claim, please complete the following: <br /> <br /> <br />EMAIL A SCANNED COPY: <br />stategrants.fiscal@library.ca.gov <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 /> <br />State of California, State Library Fiscal Office <br /> <br /> <br />ENY: 2022 ITEM NO: 6120-211-0001, Chapter 43, Statutes of 2022 <br />PURCHASING AUTHORITY NUMBER: CSL-6120 REPORTING STRUCTURE: 61202000 <br />COA: 5432000 PROGRAM #: 5312 <br /> <br />By Date <br /> (State Library Representative) <br /> <br /> <br />Grant Award #: ZIP22-68 Date: <br />Invoice #: <br /> <br />ZIP22-68-01 PO #: <br /> <br /> <br />Payee Name: Santa Ana Public Library <br /> (Legal name of authorized agency to receive, disburse and account for funds *) <br />Complete Address: <br /> Street Address, City, State, Zip Code (Warrant will be mailed to this address) <br />Amount Claimed: $9,928.00 Type of Payment: <br /> Payable Upon Execution of Agreement ☐ PROGRESS <br />Grantee Name: Santa Ana Public Library ☐ FINAL <br /> (Name on Award Letter and Agreement) ☒ IN FULL <br />Project Title: Zip Books Project ☐ AUGMENT <br />For Period From: upon execution to end of grant period <br />DocuSign Envelope ID: 39D3416E-E2CB-4407-9A82-A0F316B701C9 <br />Brian Sternberg <br />In Process