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CALIFORNIA STATE LIBRARY <br />Library Services and Technology Act <br />FINANCIAL CLAIM <br />1ST PAYMENT <br />FY: 10/11 <br />WP: 09 <br />VENDOR CODE: M719 I <br />SCHEDULE NO: Date: 3? i U t <br />Claim of: Santa Ana Public Library <br />n ?? ?? <br />Address: ??lV?iL1 QA4'`(?`C"?a?k; t)C ?"-YrtCt (Mr ('"-_7e) <br />For: Santa Ana Public Library <br />(Name of System or Agency) <br />Project Title: "Small Steps Towards Healthy Living/Pasos Pequenos Para Una Vida <br />Amount Claimed: $25,200 Grant Award I.D. Number: 40-7793 <br />For Period From: upon execution to end of grant period <br />Type of Payment: PROGRESS FINAL IN FULL <br />Payable Upon Execution of Agreement 02/16/11 <br />CERTIFICATION <br />I hereby certify under penalty of perjury: that I am the duly authorized officer <br />of the claimant herein; that this claim is in all respects true, correct and in <br />accordance with law and the terms of the contract; and that payment has not <br />previously been received for the amount claimed herein. <br />Y <br />(Signature of the uthorized <br />officer of th'e` Fiscal Agency) <br />(Title) <br />-------------------------------------------------------------------------------------------- 12? -a ------------ <br />State of California <br />State Library Fiscal Office <br />by <br />date <br />MAIL ONE ORIGINAL SIGNATURE TO: <br />California State Library <br />Fiscal Office - LSTA <br />P.O. Box 942837 <br />Sacramento, CA 94237-0001 <br />20A-10