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FLORIDA DEPARTMENT OF HEALTH <br />EMERGENCY MEDICAL SERVICES (EMS) GRANT SECTION <br />REQUEST FOR GRANT FUND DISTRIBUTION <br />IIn 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 Payment 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 />Mailing Address: 1800 27th Street <br />Vero Beach, FL 32960 <br />Federal Identification number: VF 59-60006764 <br />Authorized County Official: <br />Signature <br />Joseph E. Flescher <br />Type or Print Name and Title <br />11/14/2017 <br />Date <br />Sign and return this page with your application to: <br />Florida Department of Health <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 Emeraencv Medical Services Proaram <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 Object Code Category <br />64-61-70-30-000 05 SF005 750000 059998 <br />Federal Tax ID: VF <br />Grant Beginning Date: <br />Grant Ending Date: <br />DH 1767P, December 2008 64J-1.015, F.A.C. <br />3 <br />P103 <br />