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40 <br />8 APPLICATION (Requires Signature) <br />REQUEST FOR COUNTY GRANT DISTRIBUTION (ADVANCE PAYMENT) <br />EMERGENCY MEDICAL SERVICES (EMS) <br />COUNTY GRANT PROGRAM <br />In accordance wide die provisions of section 401.112(2)(a), F.S., the undersigned hereby <br />requests an EMS county grant distribution (advance payment) for die improvement and <br />expansion of preliospital EMS. <br />Payment To: Indian River County Board of County Commissioners <br />Name of Board of County Commissioners (Payee) <br />Federal `I'.... Nu�Nerof County: VF596000674 <br />Authori ' g County Official <br />SIGNUVRE: Date: y-;2/_9 <br />PrinteR. Macht Title: Chairman, Ward of County <br />Commissioners <br />SIGN AND RETURN WITH YOUR GRANT APPLICATION TO: <br />Department of Health <br />Bureau of Emergency Medical Services <br />EMS County Grants <br />2002D Old St. Augustine Road <br />Tallahassee, Florida 32301-4881 <br />For Use Only by Department of Health <br />Bureau of Emergency Medical Services <br />Amount: $ Grant Number: <br />Approved By: Date: <br />Signature, State EMS Grant Officer <br />Fiscal Year: Amount:$ <br />Or anization Code E$ - Ob <br />..O. •ec� t Code <br />_UUU <br />Federal Tax I. D. VF 730060 <br />Beginning Date: Ending Date: <br />