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CALIFORNIA STATE LIBRARY FINANCIAL CLAIM <br />California Library Literacy and English Acquisition Services PAYMENT IN FULL <br />CERTIFICATION <br />I hereby certify under penalty of perjury: that I am the duly authorized representative of the claimant herein; <br />that this claim is in all respects true, correct and in accordance with law and the terms of the agreement; and <br />that payment has not previously been received for the amount claimed herein. <br />By <br />(Signature of the Authorized Representative) <br />(Print Name) (Title) <br />*Legal payee name must match the payee’s federal tax return. Warrant will be made payable to payee name. Payee <br />discrepancies in name and/or address may cause delay in payment. If you need to change payee name and/or address, <br />please contact Fiscal Services at stategrants.fiscal@library.ca.gov. <br />If you are not using DocuSign electronic signature to submit your claim, please complete the following: <br />EMAIL A SCANNED COPY: <br />Stategrants.fiscal@library.ca.gov <br />MAIL ONE ORIGINAL SIGNATURE TO: <br />California State Library <br />Fiscal Office –State Funded Programs <br />PO Box 942837 <br />Sacramento, CA 94237-0001 <br />State of California, State Library Fiscal Office <br />ENY: 2021 ITEM NO: 6120-2131-0001, Chapter 240, Statutes of 2021 <br />PURCHASING AUTHORITY NUMBER: CSL-6120 REPORTING STRUCTURE: 61202000 <br />COA: 5432000 PROGRAM #: 5312 <br />By Date <br />(State Library Representative) <br />Grant Award #: Date: <br />Invoice #: PO #: <br />Payee Name: <br />ESL21-2-53 <br />ESL21-2-53-01 <br />San Leandro Public Library <br />(Legal name of authorized agency to receive, disburse and account for funds*) <br />Complete Address: <br />Street Address, City, State, Zip Code (Warrant will be mailed to this address) <br />Amount Claimed: Type of Payment: <br />☐PROGRESS <br />Grantee Name: ☐FINAL <br />☒IN FULL <br />Project Title: <br /> $ 18,790.00 <br /> <br />☐AUGMENT <br />Payable Upon Execution of Agreement <br />San Leandro Community Library <br />(Name on Award Letter and Agreement) <br />English as a Second Language Services Grant <br />For Period From: upon execution to end of grant period <br />DocuSign Envelope ID: DCA8C45C-40E8-4A10-8C66-47E0D13A5032 <br />In Process