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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 /> The agency name, address, and federal ID number must be in the 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 Board of County Commissioners <br /> Mailing Address: 1800 27th Street <br /> Vero Beach, FL 32960 <br /> Federal 9-digit Identification number: VF 59-60 6 3-digit seq. code 070 <br /> Authorized County Official: ( .( _ 12-03-2019 <br /> Si• •ature Date <br /> usan Adams, Chairman <br /> Type or Print Name and Title <br /> Sign and return this page with your application to: <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: C80 <br /> Approved By: <br /> Signature of State EMS Unit Supervisor Date <br /> Approved By: <br /> Signature of Contract Manager Date <br /> State Fiscal Year: 2019 - 2020 <br /> Organization Code E.O. OCA Object Code Category <br /> 64-61-70-30-000 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 F.A.C.64J-1.015 <br /> 3 <br />