Laserfiche WebLink
Docusign Envelope!D: 8530CBCD-5AA9-4E36-B236-387775C6289D <br />CALIFORNIA <br />O` STATE LIBRARY <br />CALIFORNIA LIBRARY SERVICES ACT <br />FINANCIAL CLAIM <br />PAYMENT IN FULL <br />Grant Award #: ZIP24-73 <br />Date: 10/7/2024 <br />Invoice #: ZIP24-73-01 PO #: 7709 <br />Payee Name: Santa Ana Public Library <br />(Legal name of authorized agency to receive, disburse and account for funds*) <br />Complete Address: 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: $13,627 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) 0 IN FULL <br />Project Title: 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 />By ESigned by, <br />fNat,, S vtJt-q <br />04A5A022A08E4F3... <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.fiscaICcDlibra ry.ca.gov. <br />State of California, State Library Fiscal Office <br />ENY: 2024 <br />PURCHASING AUTHORITY NUMBER: CSL-6120 <br />COA: 5432000 <br />FAIN: LS or N/A <br />O6y: <br />By E.I.S11-d <br />fst qua. Ud 6L, <br />77S28E5969EF401.. <br />(State Library Representative) <br />ITEM NO: 6120-211-0001, Chapter 22, Statutes of 2024 <br />REPORTING STRUCTURE: 61202000 <br />PROGRAM #: 5312 <br />Date 10/8/2024 <br />