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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 Pavment To: <br />The county name, address, and corresponding federal ID number used herein must be in the state <br />MyFloridaMarketPlace (MFMP) system. A finance person in your organization who does business with the state <br />can provide these. <br />Name of County: Indian River County Board of County Commissioners <br />Mailing Address: 1800 27" Street <br />Vero Beach, FL 32960 J/ <br />f <br />Federal 9 -digit Identification number: VF 59-60006764 ; = 3 -digit seq. code 070 <br />Authorized County Official: _ '' C <br />Si4aatwre Date <br />Joseph Earman Chairman <br />Type or Print Name and Title <br />Attest: Jeffrey R. Smith, Clerk of Sign and return this page with your application to: APPROVED AS �TO FOR <br />Circuit Court and Comptroller A ND LEGAL S C }= F i G I E N i <br />Florida Department of Health <br />��.�� Emergency Medical Services Unit, Grants BY <br />4052 Bald Cypress Way, Bin A-22 <br />Deputy L - N �R�E� INGO— <br />L0Tallahassee, Florida 32399-1722 OOUAN <br />AIFTORNEY <br />Do not write below this line. For use by State Emergency Medical Services Section <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: 2022 - 2023 <br />Grant ID: Code: <br />Organization Code E.O. OCA Object Code <br />64-61-70-30-000 05 SF005 751000 <br />Federal Tax ID: VF _ _ _ — _ _ _ Seq. Code: <br />Grant Beginning Date: Grant Ending Date: <br />Date <br />Date <br />Category <br />059998 <br />DH 1767P, December 2008 (rev. June 8, 2018), incorporated by reference in F.A.C. 64J-1.015. <br />3 <br />