CALIFORNIA STATE LIBRARY INVOICE #: 40-9281-001
Library Services and Technology Act
PO #:
FINANCIAL CLAIM
FY: 21/22
FAIN: LS-246522-OLS-20
ITEM NO: 6120-211-0890, Chapter 21, Statutes of 2021
PURCHASING AUTHORITY NUMBER: CSL-6120
REPORTING STRUCTURE: 61202000
COA: 5432000
PROGRAM #: 5312
DATE: _____________________
Claim of: San Leandro Public Library
Address: __________________________________________________________________________ For: San Leandro Public Library
(Name of System or Agency)
Project Title: Memory Lab
Amount Claimed: $19,360 Grant Award Number: 40-9281
For Period From: upon execution to end of grant period
Type of Payment PROGRESS FINAL IN FULL
Payable Upon Execution of Agreement
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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)
_____________________________________
(Title)
------------------------------------------------------------------------------------------------------------------------------------------- State of California, State Library Fiscal Office
by _____________________________________ date _____________________________________ (State Library representative)
MAIL ONE ORIGINAL SIGNATURE TO:
California State Library
Fiscal Office – LSTA
P.O. Box 942837
Sacramento, CA 94237-0001