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REQUEST FOR COUNTY GRANT DISTRIBUTION (ADVANCE PAYMENT) <br />EMERGENCY MEDICAL SERVICES (EMS) <br />GRANT PROGRAM FOR COUNTIES <br />Ia aecadenee .skis sheprrWslan a/sea m 401.113R1(a), ?.S.. d4 mederstred hereby requests as EMS away vise Al,alewew <br />( Nrionnt)for . improwwwtt and apasetas ofprr-hese at EMS. <br />Indian River County <br />PyrovessTo: Anard of ('ntinfy [`nmmiaainncsrS <br />Nae of leant alCouney firs (Pew) <br />1840 25th Street <br />Vero Beach, FL 32960 <br />Mimi Taro Airtvber gicotwty: 59-6000674 <br />(til (m) MO <br />Tad Retested County Gran tAmount: i 31,143.00 <br />SIGN4TVRE <br />httwdNarw: Richard N. Bird plc Chairman <br />Date: e- n- 9/ <br />SIGN AND RETURN WITH YOUR GRANT AI'PIJC:t IION TO: <br />Depawwn, of Health end Rshabll/tadw <br />S ,Wags <br />Office ofEawrgeery Medical Services <br />EMS Canty Grunts <br />1317 Wlnewood Boulevard <br />Tallahassee, Florida 323990700 <br />nam fitta C% <br />Approved <br />' <br />3ate <br />Admin, <br />_ <br />Laval <br />4 . 1 <br />1.1- <br />ti <br />Budget <br />q- <br />(1—els <br />Dept. <br />«— <br />is _91 <br />Risk Mgr. <br />Ateat•.4 <br />x 67. <br />Amount: $ <br />For Use Only by Dvpatmeat of IIemW. ad Rehabilitative Services, <br />Oki 0/Emergeney Medkal Servka <br />Grunt Number: <br />Approved By: Dau: <br />Signature, State EMS Grant Officer <br />Fiscal Year: <br />Oreanlzation Code <br />60-20-60-30-100 <br />Federal Tax LD. V F <br />Beginning Date: <br />Amount: $ <br />XR <br />Obiect Code <br />730060 <br />Ending Date: <br />