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FLORIDA DEPARTMENT OF HEALTH <br />EMERGENCY MEDICAL SERVICES (EMS) GRANT PROGRAM <br />REQUEST FOR GRANT FUND DISTRIBUTION <br />In accordance with the provisions of Section 401.113(2) (a), Florida Statutes, the undersigned hereby requests <br />an EMS grant fund distribution for the improvement and expansion of pre -hospital EMS. <br />DOH Remit Payment To: <br />Name of Agency: Indian River County Board of County Commissoners <br />Mailing Address: 1800 27th Street <br />Vero Beach, FL 32960 <br />Federal Identification number: VF 59-60006764 <br />Authorized County Official: <br />Signature Date <br />Bob Solari, Chairman Board of County Commissoners <br />Type or Print Name and Title <br />Sign and return this page with your application to: <br />Florida Department of Health <br />Emergency Medical Services Program, Grants <br />4052 Bald Cypress Way, Bin A-22 <br />Tallahassee, Florida 32399-1722 <br />Do not write below this line. For use by State Emergency Medical Services Program <br />Grant Amount For State To Pay: $ Grant ID: Code: C40 <br />Approved By : <br />Signature of State EMS Grant Officer Date <br />State Fiscal Year: 2015 - 2016 <br />Organization Code E.O. OCA Object Code Category <br />64-61-70-30-000 05 SF005 750000 059998 <br />Federal Tax ID: VF <br />Grant Beginning Date: Grant Ending Date: <br />DH 1767P, December 2008 64J-1.015, F.A.0 <br />3 <br />303- <br />