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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 county name, address, and corresponding federal ID number r; USIL be in the state MyFloridaMarketPlace <br />(MFMP) system. A finance person in your organization who does business with the state must provide these. <br />Name of County: 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 59-60006764 <br />Authorized County Official: <br />3 -digit seq. code 070 <br />Signature Date <br />Joseph E. Flescher, Chairman <br />Type or Print Name and Title <br />December 1, 2020 <br />Sign and return this page with your application to: APPROVED AS TO FORM <br />Florida Department of Health AiND LEGAL SUFFICIENC` <br />Emergency Medical Services Unit, Grants <br />4052 Bald Cypress Way, Bin A-22 BY <br />Tallahassee, Florida 32399-1722 DYLAN 2EIiNGOLD <br />COUNTY A T l 0R1-iEY <br />Do not write below this line. For use by State <br />Grant Amount for State to Pay: $ <br />Approved By: <br />Approved By: <br />Signature of State EMS Unit Supervisor <br />Signature of Contract Manager <br />State Fiscal Year: 2020-2021 <br />Organization Code E. 0. OCA <br />64-61-70-30-000 05 SF005 <br />Federal Tax ID: VF <br />Grant Beginning Date: <br />envy Medical Services Section <br />Grant ID: Code: <br />Date , ` FLORIDA <br />I INDIAN RIVER COUNTY <br />CERTIFY THAT THIS IS <br />Date...: ;%ND CORRECT COPY OF <br />;E ORIGINAL ON FjLE IN THIS <br />FF I e 6' <br />I BY /.Z <br />Object Code CategoryrE <br />751000 059998 '_ <br />Sequence Code: _ <br />Grant Ending Date: <br />R. <br />DH 1767P, December 2008 (rev. June 8, 2018), incorporated by reference in Rule 64J-1.015, Florida Administrative Code <br />3 <br />