Laserfiche WebLink
DocuSign Envelope ID: 559950F4-C2A7-4C48-AD17-D6B4EF4D5FB6 <br />012 "A,LIFORNIA <br />04 STATE LIBRARY <br />INFRASTRUCTURE — BUILDING FORWARD <br />FINANCIAL CLAIM <br />Is'PAYMENT <br />Grant Award #: BF-23-011 Date: 1/3/2024 <br />Invoice #: 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 />$543,377.00 Type of Payment: <br />(Payable Upon Execution of Agreement) - ® <br />PROGRESS <br />Grantee Name: <br />City of Santa Ana ❑ <br />FINAL <br />(Name on Award Letter and Agreement) ❑ <br />IN FULL <br />Project Title: <br />Newhope Library Renovation Project ❑ <br />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 CB u919ned by: <br />fltM1 ShA i-V fj <br />9M6A922ABBE4FB.., <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 stateorants.fiSCal(cDllbrarv.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 />ITEM NO: 6120-1613-0001, Chapter 12, Statutes of 2023 <br />REPORTING STRUCTURE: 61202000 <br />PROGRAM #: 5312 <br />Bo9vaiceen by: <br />By EtS nia 0/ ��1 <br />� Date 1/4/2024 <br />II929E6969EF491... <br />(State Library Representative) <br />