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40 GRANT NAME: Department of Health County Grant Funds GRANT # AMOUNT OF GRANT: $51,865.23 DEPARTMENT RECEIVING GRANT: Emergency Medical Services CONTACT PERSON: Douglas M. Wright, Director PHONE NUMBER: 561-567-8000 ext. 225 1. 2. 3. 4. 5. 6. 7 8. How long is the grant for? 2 years Starting Date: October I, 1999 Does the grant require you to fund this function after the grant is over? Yes X No Does the grant require a match? Yes X No Ifyes, does the grant allow the match to be In Kind Services? Yes No Percentage of match % Grant match amount required $ Where are the matching funds coming from (i.e. In Kind Services; Reserve for Contingency)? Does the grant cover capital costs or start -tip costs'?Yes No If no, how much do you think will be needed in capital costs or start up costs (Attach a detail listing of costs) $ Are you adding any additional positions utilizing the grant funds'?Yes ___X_No If yes, please list. (If additional space is needed, please attach a schedule.) r_— Acct. Description Position Position Position Position Position 011.12 Regular Salaries 011.13 Other Salaries & Wages (PT) 012.11 Social Security 012.12 Retirement -Contributions 012.13 Insurance -Life & Health 012.14 Worker's Compensation 012.17 S/Sec. Medicare Matching $ TOTAL 9. What is the total cost of each position including benefits, capital, start-up, auto expense, travel and operating? Salary and Benefits Operating Costs Capital Total Costs I 10. What is the estimated cost of the grant to the county over five years? $_2,500 (possible repairs and maintenance) Grant Other Match Costs First Year $ $ $ $ Second Year $ $ $ $ – - Third Year $ $ $ $ Fourth Year $ $ $ $ Fifth Year $ $ $ $