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• CALIFORNIA STATE LIBRARY <br />Library Services and Technology Act <br />FINANCIAL CLAIM <br />FY: 11/12 <br />WP: 10 <br />VENDOR CODE: M719 <br />SCHEDULE NO: <br />Claim of: Santa Ana Public Library <br />DATE: i 1?) I I I <br />Address: PV - , '!?DCAULam. TLk``?,-, i CA C1 4,37 0 <br />For: Santa Ana Public Library <br />(Name of System or Agency) <br />Project Title: Santa Ana Youth Overcoming Obstacles, One Discussion at a Time <br />Amount Claimed: $3,000 Grant Award Number: 40-8039 <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 1/20/2012 <br />--------------------------------------------------------------------------------------------------------------- <br />CERTIFICATION <br />I hereby certify under penalty of perjury: that I am the duly authorized <br />representative of the claimant herein; that this claim is in all respects true, <br />correct and in accordance with law and the terms of the agreement; and that <br />payment has not previously been received for the amount claimed herein. <br />by •1. C- '? g?d <br />(Signature of th authorized representative) <br />------------------------------------------------------------------------------------ Title------------` <br />------------------------------------- <br />State of California <br />State Library Fiscal Office <br />by <br />(State Library representative) <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