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APPLICATION ITEM 16 (signature required) <br />UEST FOR MATCHING GRANT DISTRIBUTION (ADVANCE PAYMENT) <br />EMERGENCY MEDICAL SERVICES (EMS) <br />Governmental Agency and Non-profit Entity ONLY <br />In accordance with the provisions of paragraph 401.113(2)(b). F.S.. the undersigned hereby requests an EMS matching <br />grant distribution (advance payment) for the improvement and expansion of prehospital EMS. <br />Payment To: <br />Indian River County Emergency Medical Services <br />Legal Name of Agency/Organisation <br />1840 25th Street <br />Vero Beach <br />(City) <br />Address <br />FL 3.7960 <br />(State) (gip) <br />thorized Official <br />SIGNATURE: "DATE: //- / i • <br />Printed Name: Richard N. Bird <br />Title: Chairman <br />SIGN AND RETURN WITH YOUR MATCHING GRANT APPLICATION TO: <br />Department of Health and Rehabilitative Services <br />Office of Emergency Medical Services (HSTM) <br />EMS Matching Grants <br />1317 Winewood Boulevard <br />Tallahassee. Florida 32399-0700 <br />Foe Vas Only by Deponent of Health and Rehabilitative $. vires, <br />Me of B+eerproy Medical Services <br />Matching Grant Amount:$ Grant ID Code: <br />Approved By: Date: <br />Signature. Title. State EMS Grant Officer <br />Stag Fiscal Year: Amounts $ <br />Organization Codt <br />60-20-60-30-100 <br />Las <br />HS <br />Obiect Cod* <br />Federal Tax ID V Ft <br />Grant Beginning Data: Ending Data: <br />