CA LIBRARY LITERACY AND ENGLISH ACQUISITION SERVICES
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: 2024 ITEM NO: 6120-213-0001, Chapter 22, Statutes of 2024 PURCHASING AUTHORITY NUMBER: CSL-6120 REPORTING STRUCTURE: 61202000 COA: 5432000 PROGRAM #: 5312
FAIN: LS or N/A
By Date
(State Library Representative)
Grant Award #: CLLS24-66 Date:
Invoice #: CLLS24-66-01 PO #: 7631
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: $43,946 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 Services ☐ AUGMENT For Period From: upon execution to end of grant period
Docusign Envelope ID: 996F0991-91A4-4FF7-821F-B84A0799AAE7