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GRANT NAME• EMS County Grant AMOUNT OF GRANT: $ 45.920.00 GRANT # C40 - DEPARTMENT RECEIVING GRANT. Fire Rescue CONTACT PERSON• Brian Burkeen 1. How long is the grant for? 1 Year 2. Does the grant require you to fund this function after the grant is over? 3 Does the grant require a match? If yes, does the grant allow the match to be In -Kind services? TELEPHONE• 772-226-3864 Starting Date: December 16, 2015 X Yes No Yes X No Yes No 4. Percentage of match to grant 0.00 5 Grant match amount required S 0 00 6 Where are the matching funds coming from (i.e. In -Kind Services; Reserve for Contingency)? 7 Does the grant cover capital costs or start-up costs? X Yes No If no, how much do you think will be needed in capital costs or start-up costs: $ (Attach a detail listing of costs) 8. Are you adding any additional positions utilizing the grant funds? If yes, please list. (If additional space is needed, please attach a schedule.) Yes X No Acct. Description Position Position Position Position Position 011.12 Regular Salaries $45,920.00 Second Year $ $ $ 011.13 Other Salaries & Wages (PT) $ $ $ $ Fourth Year 012 11 Social Security $ $ Fifth Year $ $ 012.12 Retirement — Contributions 012 13 Insurance —Life & Health 012.14 Worker's .Compensation 012.17 S/Sec. Medicare Matching TOTAL 9. What is the total cost of each position including benefits, capital, start-up, auto expense, travel and operating? Salary and Benefits Operating Costs Capital Total Costs Total 45,920.0.0 $45,920.00 45,920.00 $0.00 $45,920.00 Second Year $ $ $ $ Third Year $ $ $ $ Fourth Year $ $ $ 10 What is the estimated cost of the grant to the county over five years? S ��""y '``� •_ .�>�, _ =- x1 Grant Amount Other Match Costs Not Covered Match Total First Year $45,920.00 $0 00 $0.00 $45,920.00 Second Year $ $ $ $ Third Year $ $ $ $ Fourth Year $ $ $ $ Fifth Year $ $ $ $ Signature of Preparer Date: December 2, 2015 298