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CLAIM FORM
California Library Literacy and English Acquisition Services Program (CLLS)
FY 2012/2013
California Education Code; Sections 18880-18884 •CSL Budget Item 6120-213-0001
The National City Public Library
claims the indicated allowance for the
purposes of carrying out the functions stated in its CLLS application and in Sections 18880-18884 of
the California Education Code.
I hereby certify under penalty of perjury: that the library named above shall use their allowance solely
for the purposes indicated in their CLLS application and in Sections 18880-18884 of the California
Education Code.
Minh Duong
ibra Director (Signature) Typed Name of Signatory
CLAIM FOR PAYMENT OF GRANT
Claim of National City Public Library
Name of Authorized Library
Address 1 401 National City Blvd., National City CA 91 950
Amount Claimed: $43, 41 0
CERTIFICATION
Date 8/29/2012
hereby certify under penalty of perjury: that I am the duly authorized officer of the claimant herein; that
the claim is in all true, correct and in accordance with law and that payment has not previously been
receivedJor the amount claimed herein.
By
Official-f7epresentative oTiscal Agent (Signature Required)
Note: Warrant to be ised or payment to the library to be addressed to:
National City Public Library
City Librarian
Title
(Authorized agency to receive, disburse and account for CLLS funds)
1401 National City Blvd., National City CA 91950
Mail to:
California State Library,
Fiscal/Local Assistance
P.Q. Box 942837
Sacramento, CA 94237-0001
(Address of above agency)
Approval by State:
State Library Local Assistance Office Use Only
California Library Literacy Services $
BY: DATE: