Grant Award Signed - Memory Lab 12302021

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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 ------------------------------------------------------------------------------------------------------------------------------------------- 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 DocuSign Envelope ID: BFA82BFD-E288-4CA3-B9FB-BAC4531C0FB0 2/23/2022 300 Estudillo Ave. San Leandro, CA 94577 Library Director In Process