Richmond Public Library Invoice #ESL21-22
PLEASE COMPLETE AND RETURN THIS PAGE
Claim Form
State of California
California Library Literacy and English Acquisition Services (CLLS) California Education Code; Section 18880-18883
Budget Citation Chapter 21 - Budget Item 6120-213-0001
Fiscal Year: 2021-2022
Reporting Structure: 61202000 COA: 5432000; Approp. Ref: 213 Purchasing Authority Number: CSL-6120 Category: 84121600 Program #: 5312
EOR PAYMENT OF ENGLISH AS A SECOND LANGUAGE SERVICES GRANT Amount Claimed - $21,700
$21,700 for ESL (100% of award)
City of Richmond, Finance Dept. - Grants, 450 Civic Center Plz, Richmond, CA 94804-1630 claims the indicated allowance for the purposes of carrying out the functions stated in its ESL application and in Sections 18880-18883 of the California Education Code.
Warrant to be issued for payment to the library to be addressed to:
(Authorized agency to receive, disburse and account for CLLS funds) I hereby certify under penalty of perjury: that the library named above shall use their allowance solely for the purposes indicated in their ESL application and in Sections 18880-18883 of the California Education Code.
Official Representative or Fiscal Agent (Signalure Required) Title EMAIL A COPY OF YOUR EXECUTED MAIL ONE ORIGINAL SIGNATURE TO:
CLAIM AND CERTIFICATION TO: California State Library
[email protected] AND Fiscal Office - CLLS
Email Subject: P. O. Box 942837
Claim and Certification - ESL Grant -
ESL21-22 Sacramento, CA 94237-0001
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State Library Local Assistance Office Use Only
Approval by State:
STATE OF CALIFORNIA, State Library Fiscal Office
CLLS $
By Date:
State Library Representative
*The warmont address must match that on file in FiSCal. If you need to change the authorized library name and/or address, please contact Nicole Bravin, CSL Fiscal Office. ([email protected])