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CALIFORNIA STATE LIBRARY <br />Library Services and Technology Act <br />FINANCIAL CLAIM <br />IST PAYMENT <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: 2C C, •� C �ntr,- t'l< <br />For: Santa Ana Public Library <br />(Name of System or Agency) <br />INVOICE #: 40.8787-001 <br />T, 0 6 -) <br />DATE: r <br />1/-1 7 <br />C +fi yHc,ll ��m ,y <br />Project Title: Youth Know: Community Social Innovation Project <br />Amount Claimed: $29,610 Grant Award Number <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 />F� 76/) / <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 />(Signature of the4authorized representative) <br />----------------------------------------------------- <br />----------------------------------- - --- --- ----- ---------------- <br />State of California, State Library Fiscal Officenr?�rea<I�/ <br />bydate <br />(Stat Li racy re rese e) <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 />