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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: 1840 25th Street Vero Beach Florida 32960 <br />Federal Identification number VF 59-6000674 <br />Authorized Official: <br />March 13, 2007 <br />ignature Date <br />Gary C. Wheeler, 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 Object 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 />STATE OF FLORIDA <br />INDIAN RIVER COUNTY • <br />THIS IS TO CERTIFY THAT THIS IS <br />A TRUE AND CORRECT COPY OF <br />THE ORIGINAL ON FILE IN THIS <br />;OFFICE <br />JEFFREY K. B R • N, CLER <br />'BY6141d , <br />DATE <br />D.C. <br />