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do <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) <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 County Commissioners <br />Address .1840 25" Street <br />I <br />City :Vero Beach State: Florida Zip: 32960 <br />Authorized Official <br />Signature ate <br />Kenneth R. Macht. Chairmal Lt- 2 2 <br />Type Name and Title <br />Sign and return this page with your application to: <br />Florida Department of Health <br />SEMS Rural Matching Grants Program <br />2002 - D Old St. Augustine Road <br />Tallahassee. Florida 32301-4881 <br />Do not write below this line For use by BEMS personnel only <br />Matching Grant Amount for State to Pay: Grant ID. Code: M <br />Approved By: <br />Signature & Title of BEMS Grant Officer Date <br />State Fiscal Year:-- <br />Organization <br />ear: Organization Code E. 0. Obiect Code <br />64-25-60-00-000 13U 7 <br />Federal Tax ID: VF_ _ <br />DH Form 1767P, Fffective Jan. 99, Revised Feb. 99 <br />