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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 Pavment To: <br />The agency name, address, and federal ID number must be in the state MyFloridaMarketPlace (MFMP) <br />system. Ask a finance person who does business with the state for your organization to provide these. <br />Name of Agency: Indian River County Board of County Commissioners <br />4.4 <br />0 <br />Mailing Address: 1800 27th Street <br />9 <br />Vero Beach FL 32960 �,iY COnjl <br />U O <br />Federal Identification number: VF 59-60006764p <br />_ :v <br />U <br />Authorized County Official: :' 1/14/2017 <br />.: <br />a 1 <br />igna ure •• Dpfe i <br />• •'�9.00UPITYF�,ZoP. <br />Joseph E. Flescher . Chairman ...... <br />4 0 <br />4 U <br />Type or Print Name and Title <br />h <br />Sign and return this page with your application to: <br />W <br />Florida Department of Health <br />Fi <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: C60 <br />Approved By: <br />Signature of State EMS Grant Officer Date <br />State Fiscal Year: 2017 - 2018 <br />Organization Code E.O. OCA Obiect Code Cateaory <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.C. <br />3 <br />