Richmond Public Library Invoice #ESL21-22
PLEASE COMPLETE AND RETURN THIS PAGE
CERTIFICATION
I hereby certify under penalty of perjury: that I am the duly authorized representative of the claimant herein; that the 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.
The 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.
City of Richmond, Finance Dept. - Grants, 450 Civic Center Plz, Richmond, CA 94804-1630
SIGNED DATE
Signature - Authorized representative
Typed/Printed Name and Title of Authorized Representative Email address of authorized representative
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MAIL ONE ORIGINAL SIGNATURE TO:
California State Library
Fiscal Office - CLLS
P. O. Box 942837
Sacramento, CA 94237-0001