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f <br />APPLICATION ITEM 16 (signature required) <br />VEST 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 underaiped hereby requesfa as EMS mating <br />grant distribution (advance payment) for the improvement and expaoaion of prehospital EMS. <br />Payment To: <br />• <br />Indian River County Emergency Medical Services <br />Legal Name of Agency/Organization <br />1840 25th Street <br />Vero Beach. <br />(City) <br />Address <br />FL 3296A <br />(State) (Zip) <br />thorized Official <br />SIGNATURE: �DATE // - / <br />Printed Name: Richard N. Bird 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 />Far the Only by Dpannnat of Health and R.Mbnhadva Swaim, <br />Guise of Emstproy Mulled Unica <br />Matching Grant Amount:$ Grant ID Code: <br />Approved By: Date: <br />Signature. Title. State EMS Grant Officer <br />Stats Fiscal Years Amounts $ <br />Oraanization Cods <br />60-20-60-30-100 <br />=•O. <br />HS <br />Obiect Cod, <br />Federal•Tax ID V Fs <br />Grant Beginning Dates Ending Dates <br />• <br />