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<br />California Library Literacy and English Acquisition Services <br />FINANCIAL CLAIM <br />PAYMENT IN FULL <br /> <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 /> <br /> <br /> (Signature of the Authorized Representative) <br /> <br /> <br /> <br /> (Print Name) (Title) <br /> <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 /> <br /> <br /> <br />State of California, State Library Fiscal Office <br /> <br /> <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 /> <br />By Date <br /> (State Library Representative) <br />Grant Award #: ESL21-3-41 Date: <br />Invoice #: <br /> <br />ESL21-3-41-01 PO #: <br /> <br /> <br />Payee Name: 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: $23,488 Type of Payment: <br /> (Payable Upon Execution of Agreement) ☐ PROGRESS <br />Grantee Name: San Leandro Public Library ☐ FINAL <br /> (Name on Award Letter and Agreement) ☒ IN FULL <br />Project Title: English as a Second Language ☐ AUGMENT <br />For Period From: upon execution to end of grant period <br />DocuSign Envelope ID: E3D1E6B5-ECD8-45D7-B4CD-230528B8419F <br />Brian Simons Library Director <br />7/19/2023 <br />300 Estudillo Ave. San Leandro, CA 94577 <br />6334 <br />7/19/2023