In Process
CALIFORNIA STATE LIBRARY FINANCIAL CLAIM California Library Literacy & English Acquisition Services Program 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].
If you are not using DocuSign electronic signature to submit your claim, please complete the following:
EMAIL A SCANNED COPY:
[email protected]
MAIL ONE ORIGINAL SIGNATURE TO:
California State Library
Fiscal Office –State Grants
PO Box 942837
Sacramento, CA 94237-0001
State of California, State Library Fiscal Office
ENY: 2022 ITEM NO: 6120-213-0001, Chapter 43, Statutes of 2022 PURCHASING AUTHORITY NUMBER: CSL-6120 REPORTING STRUCTURE: 61202000 COA: 5432000 PROGRAM #: 5312
By Date
(State Library Representative)
Grant Award #: CLLS22-68 Date:
Invoice #:
CLLS22-68-01 PO #:
Payee Name: City of Riverside Public Library
(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: $49,731 Type of Payment:
Payable Upon Execution of Agreement ☒ PROGRESS
Grantee Name: Riverside Public Library ☐ FINAL (Name on Award Letter and Agreement) ☐ IN FULL
Project Title: California Library Literacy & English
Acquisition Services Program
☐ AUGMENT
For Period From: upon execution to end of grant period
DocuSign Envelope ID: E3EBEBDD-243A-4369-BACB-29591E874AE2