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CALIFORNIA STATE LIBRARY <br />Library Services and Technology Act <br />FINANCIAL CLAIM <br />1ST PAYMENT <br />FY: 11/12 <br />WP: 10 <br />VENDOR CODE: M719 <br />SCHEDULE NO: <br />Claim of: Santa Ana Public Library <br />RM 27 <br />10li.71i4 <br />Address( C`'l�'t��Y �r'1CLZr ; ScLia. �4�1c�; G7C'1 <br />For: Santa Ana Public Library <br />(Name of System or Agency) <br />Project Title: "For Your Info Santa Ana /Para su info Santa Ana" Youth Media Ambassadors Digital <br />Media Production Project <br />Amount Claimed: $44,100 Grant Award Number: 40 -7979 <br />For Period From: upon execution to end of grant period <br />Type of Payment PROGRESS FINAL IN FULL <br />Payable Upon Execution of Agreement 10/1/2011 <br />CERTIFICATION <br />I hereby certify under penalty of perjury: that I am the duly authorized <br />representative of the claimant herein; that this claim is in all respects true, <br />correct and in accordance with law and the terms of the agreement; and that <br />payment has not previously been received for the amount claimed herein. <br />by <br />(Signature of tM authorized representative) <br />State of California <br />State Library Fiscal Office <br />by <br />date <br />(State Library representative) <br />' iV't- 1> <br />(Title) (vk1CA '�- �yvjrylLkvlfhti !2*+YV'iO3 <br />-------------------------------------------------------- - --- -- <br />MAIL ONE ORIGINAL SIGNATURE TO: <br />California State Library <br />Fiscal Office — LSTA <br />P.O. Box 942837 <br />Sacramento, CA 94237 -0001 <br />20A -11 <br />