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DEPARTMENT OF HEALTH <br /> EMS GRANT PROGRAM <br /> REQUEST FOR GRANT FUND DISTRIBUTION <br /> In accordance with the provisions of Section 401 . 113 (2 ) (a ) , F . S . , the undersigned <br /> hereby requests an EMS grant fund distribution for the improvement and expansion of <br /> pre- hospital EMS . <br /> DOH Remit Payment To : <br /> Name of Agency : Indian River County Board of County Commissioners , <br /> Mailing Address : 180027 th Street Vero Beach Florida 32960 <br /> Federal Identification Bumber VF 59 =6000674 <br /> Authorized Official : � � January 19 , 2010 <br /> Signature Date <br /> Peter D . O ' Bryan, Chairman Board of County Commissioners_ <br /> Type Name and Title <br /> Sign and return this page with your application to: <br /> Florida Department of Health <br /> BEMS Grant Program <br /> 4052 Bald Cypress Way, Bin C18 <br /> Tallahassee, Florida 32399- 1738 <br /> Do not write below this line. For use by Bureau of Emergency Medical Services personnel only <br /> Grant Amount For State To Pay : $ Grant ID : Code : <br /> Approved By : <br /> Signature of EMS Grant Officer Date <br /> State Fiscal Year: - <br /> Organization Code E . O . OCA Obiect Code <br /> 64-25-60-00-000 N N2000 7 <br /> Federal Tax ID : VF <br /> Grant Beginning Date : October 1 , Grant Ending Date : September 30 , <br /> DH Form 1767P , Rev . June 2002 <br /> APPROVED A > <br /> APPROVED AND L5i_a t • : 1 <br /> By ' �. . <br /> . .. . :. . . . . : . . ... . . <br /> GEORGE . Ge. <br /> ASSISTANT COUNTY ia? <br /> C ✓ (:ht Attest : J . K. Barton , Clerk <br /> ountv : Iministrator <br /> eputy Clerk <br />