Laserfiche WebLink
DocuSign Envelope ID: 559950F4-C2A7-4C48-AD17-D6B4EF4D5FB6 <br />ON <br />00 STATE LIBRARY <br />INFRASTRUCTURE — BUILDING FORWARD <br />FINANCIAL CLAIM <br />15t PAYMENT <br />Grant Award #: <br />BF-23-011 Date: 1/3/2024 <br />Invoice #: <br />BF-23-011-01 PO #: 6948 <br />Payee Name: <br />City of Santa Ana <br />(Legal name of authorized agency to receive, disburse and account for funds) <br />Complete Address: <br />26 civic center Plaza, Santa Ana, CA 92701 <br />Street Address, City, State, Zip Code (Warrant will be mailed to this address) <br />Amount Claimed: <br />$5439377.00 Type of Payment: <br />(Payable Upon Execution of Agreement) ❑x PROGRESS <br />Grantee Name: <br />City of Santa Ana ❑ FINAL <br />(Name on Award Letter and Agreement) ❑ IN FULL <br />Project Title: <br />Newhope Library Renovation 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 />BY [DocuSigned by: <br />eaun S{wln tir v� <br />04A5A022AOBE4F3._. <br />(Signature of the Authorized Representative) <br />Brian Sternberg <br />(Print Name) <br />Library Services Director <br />(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(@library.ca.gov. <br />State of California, State Library Fiscal Office <br />ENY: 2023 <br />PURCHASING AUTHORITY NUMBER: CSL-6120 <br />COA: 5432000 <br />FAIN: N/A <br />by: <br />By [DocuSigned <br />t st Iu,x U c <br />77928E5969EF401... <br />(State Library Representative) <br />ITEM NO: 6120-1613-0001, Chapter 12, Statutes of 2023 <br />REPORTING STRUCTURE: 61202000 <br />PROGRAM #: 5312 <br />Date 1/4/2024 <br />