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FLORIDA DEPARTMENT OF HEALTH <br /> EMERGENCY MEDICAL SERVICES(EMS) GRANT SECTION <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 /> The agency name and mailing address must be in the state MyFloridaMarketPlace (MFMP) system. <br /> Name of Agency: Indian River County Board of County Commissioners <br /> Mailing Address: 1800 27th Street <br /> Vero Beach, FL 32960 <br /> Federal Identification number: VF 59-60006764 <br /> Authorized County Official: ��.t,` 09/13/2016 <br /> Signature Date <br /> Bob Solari, Chairman Board of County Commissioners <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 Section, 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: C50 <br /> Approved By <br /> Signature of State EMS Grant Officer Date <br /> State Fiscal Year: 2016 - 2017 <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 />