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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 25"' Street Vero Beach Florida 32960 <br /> Federal Identification number VF 59-6000674 <br /> Authorized OfficiM-21-06 <br /> Signat Date <br /> Arthur R.Neuberger,Chairman B d 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 />