In Process
CALIFORNIA STATE LIBRARY FINANCIAL CLAIM
LIBRARY SERVICES & TECHNOLOGY ACT FINAL 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 – Federally Funded Programs
PO Box 942837
Sacramento, CA 94237-0001
State of California, State Library Fiscal Office
FAIN: LS-252449-0LS-22
ENACTMENT YEAR: 2022 ITEM NO: 6120-211-0890, Chapter 43, Statutes of 2022 PURCHASING AUTHORITY NUMBER: CSL-6120 REPORTING STRUCTURE: 61202000 ACCOUNT: 5432000 BUDGET PROGRAM: 5312
By Date
(State Library Representative)
Grant Award #: 40-9358 Date:
Invoice #:
40-9358-001 PO #:
Payee Name: 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: $20,000 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: Dia de los Ninos ☐ AUGMENT
For Period From: upon execution to end of grant period
DocuSign Envelope ID: 8E25492F-050A-4E2F-BEA9-DE61FAF805E3 Erin Christmas