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Docusign Envelope ID:8530CBCD-5AA1-4E36-B236-387775C6289D <br /> MOMil rt ES. 1 , p 1 4",. <br /> gin STATE LIBRARY <br /> CALIFORNIA LIBRARY SERVICES ACT <br /> FINANCIAL CLAIM <br /> PAYMENT IN FULL <br /> Grant Award #: ZIP24-73 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) z 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 /> ,—Signed by, <br /> By tvicuA, Sft vin,lou^o <br /> '-04A5A022AOBE4F3 <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 a(�librarv.ca.gov. <br /> State of California, State Library Fiscal Office <br /> ENY: 2024 ITEM NO: 6120-211-0001, Chapter 22, Statutes of 2024 <br /> PURCHASING AUTHORITY NUMBER: CSL-6120 REPORTING STRUCTURE: 61202000 <br /> COA: 5432000 PROGRAM#: 5312 <br /> FAIN: LS or N/A <br /> —DocuSlgned by. <br /> By (�tStlnia U1444ot, Date 10/8/2024 <br /> ' —77928E5969EF40I <br /> (State Library Representative) <br />