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FLORIDA DEPARTMENT OF HEALTH <br /> EMERGENCY MEDICAL SERVICES(EMS) GRANT.UNIT <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 Payment To: : <br /> Theagency name, address, and federal ID number must be inthe state MyFloridaMarketPlace (MFMP) <br /> system..Ask a finance person in your organization who does business with the state to provide these <br /> Name of Agency: Indian.River County Finance <br /> Mailing Address: 1801 27t''Street, Building A <br /> Vero Beach, FL.32960 <br /> Federal 9-digit Identification nu er VF 59-60006764' „v.ssior��R,s'°°,:. 3-digit seq. code 070 <br /> Authorized County Official: .e.64___ /,�0,44 �� q <br /> ✓" / •�' �10/02/2 ,18 <br /> ATTEST: Jeffr- R. Sm' lerjgnature. =z� 4,,, , : Date:o= <br /> , ourt .�.. . stroller °v i <br /> /� Peter D. O'Bryan, Chairman ►..,�•. �>:slaw_;' .: <br /> BY: i / __ Type or Print Name and Title 't: <br /> II-. y Cler. �. ••..•�'�N • 'P�o <br /> •.• DIA RN .••'± <br /> Sign and return this page with your applicafion�r . '' <br /> Florida Department of Health <br /> Emergency Medical Services Unit, 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 Section <br /> Grant Amount for State to Pay: $ Grant ID:. Code: C70 <br /> _Approved By: <br /> Signature of State EMS Unit Supervisor . . Date <br /> Approved By: Signature of Contract Manager Date <br /> State Fiscal Year: 2018 - 2019 <br /> Organization Code E.O. OCA Object Code Category _ <br /> 64-61-70-30=000 <br /> 05 SF005. 751000 059998 <br /> Federal Tax ID:VF Seq. Code: <br /> Grant Beginning Date: Grant Ending Date: - <br /> DH 1767P, December 2008(rev.June 8,2018), incorporated by reference in FAC.64J-1.015 <br /> 3 <br />