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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 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 urpo es indicated in their CLLS application and in Sections 18880-18884 of the California
Educatio Co e.
Minh Duong
Signature) Typed Name of Signatory
CLAIM FOR PAYMENT 6F"GRANT
Claim of National City Public Library
Name of Authorized Library
Address 1 401 National City Blvd. , National City CA 91 950
Amount Claimed: $3,537
Date 1 /28/201 1
CERTIFICATION
I 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
received r t amount claimed herein.
By ) City Librarian
Of presentative of Fi al Agent (Signature Required) Title
Note: Warrant to be iss'd for yment to the library to be addressed to:
National City Public Library
(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.O. 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: