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LSTA REQUEST FOR PAYMENT FORM Library Name: State Project Number: Project Name: Amount Requested: Payable To: Refer to award notification for CFDA and other grant information. Email completed form to Chris Guerra at libdev@azsos.libanswers.com. Mailing Address: I certify to the best of my knowledge and belief that the information provided herein is true, complete, and accurate. I am aware that the provision of false, fictitious, or fraudulent information, or the omission of any material fact, may subject me to criminal, civil, or administrative consequences including, but not limited to violations of U.S. Code Title 18, Sections 2, 1001, 1343 and Title 31, Sections 3729-3730 and 3801-3812. The undersigned acknowledges receipt of and agreement with the terms of the LSTA award documents, and hereby requests funds to execute the project named above. __________________________________________________________________________ Signature (Click here if you need instructions for signing this form electronically) ____________________________________________________ ____________________ Printed Name Date