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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: 1800 27th Street Vero Beach Florida 32960 <br />Federal Identification number VF 59-6000674 <br />Authorized Officia <br />Signature Date <br />„,.� • Chairman Board of County Commissioners <br />..1'� O'' MIS <br />-- <br />..• � s%' Wesley S Davis, Chairman <br />`.' St i`k and return this page with your application to: <br />5 <br />*: * : Florida Department of Health <br />1. BEMS Grant Program <br />\%.. �, • o7 4052 Bald Cypress Way, Bin C18 <br />V.7 . oQa Tallahassee, Florida 32399-1738 <br />Do ndt� k v this line. For use by Bureau of Emergency Medical Services personnel only <br />11-18-14 <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 />