LUNCH AT THE LIBRARY PROGRAM
FINANCIAL CLAIM
1st PAYMENT
CERTIFICATION
I hereby certify under penalty of perjury: that I am the duly authorized representative of the claimant herein; that this claim is in all respects true, correct and in accordance with law and the terms of the agreement; and that payment has not previously been received for the amount claimed herein.
By
(Signature of the Authorized Representative)
(Print Name) (Title)
*Legal payee name must match the payee’s federal tax return. Warrant will be made payable to payee name. Payee discrepancies in name and/or address may cause delay in payment. If you need to change payee name and/or address, please contact Fiscal Services at [email protected].
State of California, State Library Fiscal Office
ENY: 2023 ITEM NO: 6120-140-0001, Chapter 12, Statutes of 2023 PURCHASING AUTHORITY NUMBER: CSL-6120 REPORTING STRUCTURE: 61202000 COA: 5432000 PROGRAM #: 5312
FAIN: N/A
By Date
(State Library Representative)
Grant Award #: LATL23-44A Date:
Invoice #:
LATL23-44A-01 PO #:
7240
Payee Name: City of Orange
(Legal name of authorized agency to receive, disburse and account for funds*) Complete Address:
Street Address, City, State, Zip Code (Warrant will be mailed to this address) Amount Claimed: $12,758 Type of Payment:
(Payable Upon Execution of Agreement) ☐ PROGRESS
Grantee Name: Orange Public Library ☐ FINAL (Name on Award Letter and Agreement) ☒ IN FULL
Project Title: Lunch at the Library Summer 2024 ☐ AUGMENT For Period From: upon execution to end of grant period
DocuSign Envelope ID: D32B71C9-DAD9-4256-A49B-EC97A38CA354 Acting Library Director
Amy Z. Harpster
2/5/2024
407 E. Chapman Ave., Orange, CA 92866
2/6/2024