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INFRASTRUCTURE – BUILDING FORWARD <br />FINANCIAL CLAIM <br />1st PAYMENT <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: 2023 ITEM NO: 6120-1613-0001, Chapter 12, Statutes of 2023 <br />PURCHASING AUTHORITY NUMBER: CSL-6120 REPORTING STRUCTURE: 61202000 <br />COA: 5432000 PROGRAM #: 5312 <br />FAIN: N/A <br />By Date <br /> (State Library Representative) <br /> <br />Grant Award #: BF-23-011 Date: <br />Invoice #: <br /> <br />BF-23-011-01 PO #: <br /> <br />6948 <br />Payee Name: City of Santa Ana <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: $543,377.00 Type of Payment: <br /> (Payable Upon Execution of Agreement) ☒ PROGRESS <br />Grantee Name: City of Santa Ana ☐ FINAL <br /> (Name on Award Letter and Agreement) ☐ IN FULL <br />Project Title: Newhope Library Renovation Project ☐ AUGMENT <br />For Period From: upon execution to end of grant period <br />DocuSign Envelope ID: 559950F4-C2A7-4C48-AD17-D6B4EF4D5FB6 <br />Library Services Director <br />1/3/2024 <br />Brian Sternberg <br />26 Civic Center Plaza, Santa Ana, CA 92701 <br />1/4/2024