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CALIFORNIA STATE LIBRARY40-8787-0 <br />Libraryi Technology <br />FINANCIAL CLAIM <br />IST i -T x1,9 <br />FY: 17/18 <br />FAIN: LS -00-17-0005-17 <br />ITEM NO: 6120-211-0890, Chapter 14, Statutes of 2017 <br />PURCHASING AUTHORITY NUMBER: CSL -6120 <br />REPORTING STRUCTURE: 61202000 <br />COA: 5432000 <br />PROGRAM #: 5312 <br />SCHEDULE NO: <br />SCHEDULE DATE: <br />Claim of: Santa Ana Public Library <br />Address: 20 flvIG C„ }e,- l'l z—. <br />For: Santa Ana Public Library <br />(Name of System or Agency) <br />DATE: (! — iv,/- % 7 <br />FX 23 , C.✓1 k. fine,/ 1.A {)74';/ <br />Project Title: Youth Know: Community Social Innovation Project <br />' • -• $29,610 Grant Award •- 40-8 787 <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 7/1/2017 <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 />pyTyw +pw /} /�'J f/ 7o- <br />------�uthorized <br />by� <br />.Cynthia z it (Signature of the representative) <br />Interim City Manager MARIA L7.HUIZAR <br />CLERK OF THE COUNCIL <br />--{T Cj Z1L'rl� l`f -zi--------------- <br />State of California, State Library Fiscal Officen�Nrrs�<tj <br />by date <br />(State Library representative) <br />MAIL ONE ORIGINAL SIGNATURE TO: <br />P.O.California State Lib ry <br />Fiscal Office — LSTA <br />Box 942837 <br />Sacramento, CA 94237-001 <br />