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DocuSign Envelope ID:48BE736F-8B67-42CF-A595-F4DE6CBC3F74 <br /> STATE LIBRARY <br /> California Library Literacy and English Acquisition Services <br /> FINANCIAL CLAIM <br /> PAYMENT IN FULL <br /> Grant Award #: ESL21-3-34 Date: 7/21/2023 <br /> Invoice #: ESL21-3-34-01 PO #: 6344 <br /> Payee Name: Pleasanton Public Library <br /> (Legal name of authorized agency to receive,disburse and account for funds') <br /> Complete Address: 400 old Bernal Avenue, Pleasanton, CA 94566 <br /> Street Address, City, State, Zip Code(Warrant will be mailed to this address) <br /> Amount Claimed: $61,071 Type of Payment: <br /> (Payable Upon Execution of Agreement) ❑ PROGRESS <br /> Grantee Name: Pleasanton Public Library ❑ FINAL <br /> (Name on Award Letter and Agreement) FX- IN FULL <br /> Project Title: English as a Second Language ❑ AUGMENT <br /> For Period From: upon execution to end of grant period <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 /> B DocusiBnea by: <br /> y C <br /> tt" <br /> 94OF'FV, <br /> 486 <br /> (Signaturof the Authorized Representative) <br /> Gerry Beaudin <br /> City Manager <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(ar,library.ca.gov. <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 /> COX 5432000 PROGRAM #: 5312 <br /> By <br /> ED—ft-dby:rrSt�ua Ujarvc, Date 7/21/2023 <br /> 388FD493 <br /> (State Library Representative) <br />