Laserfiche WebLink
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
do <br />LA <br />Item 11 <br />FLORIDA DEPARTMENT OF HEALTH <br />EMS MATCHING GRANT PROGRAM <br />REQUEST for ADVANCE PAYMENT <br />(Governmental Agency and Not -for -Profit Entity Only) I <br />In accordance with the provisions of Section 401.113(2)(b), Florida Statutes, the undersigned hereby request <br />an EMS matching grant distribution (advance payment) for the improvement, expansion and continuation o <br />prehospital EMS. <br />Remit Payment To: <br />Name of EMS Organization :Indian River County Board of Countv Commissioners <br />Address :1840 25" Street <br />City :gnat.,.6 <br />ach State: Florida Zip: 32960 <br />Authorized Official 3 <br />Date <br />Kenneth R. Macht. Chairman <br />Type Name and Title <br />Sign and return this page with your application to: <br />Florida Department of Health <br />GEMS Rural Matching Grants Program <br />2002 - D Old St. Augustine Road <br />Tallahassee, Florida 32301-4881 <br />Do not write below tnis line For use by BEMS personnel only <br />I -- <br />Matching Grant Amount for State to Pay: $ Grant ID. Code: M <br />Approved By: <br />i, <br />Signature & Title of BEiv1S Grant Officer Date <br />State Fiscal Year: <br />Organization Code <br />64-25-60-00-000 <br />Federal Tax ID: VF <br />E.O. -bled Code <br />BU 7 <br />OH Form 1767P. Effective Jan. 99. Revised Feb 99 <br />Pid MP <br />6wMa Svo <br />rurcew.Ma MW <br />�M,� Dete <br />/ 7 <br />