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STATE OF FLORIDA <br />INDIAN RIVER COUNTY <br />THIS IS TO CERTIFY THAT THIS 15 A TRUE AND CORRECT <br />COPY OF THE ORIGINAL ON FILE IN THIS OFFICE <br />�.,, RYAN L BUTLER. CLERK <br />FLORIDA DEPARTMENT OF HEALTH DATE 0 <br />EMERGENCY MEDICAL SERVICES (EMS) GRANT IIIA <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 <br />state can provide these. <br />Name of County: Indian River County Board of County Commissioners <br />Mailing Address: 1800 271h St <br />Vero Beach, FL 32960 <br />O�y�phSMlSSjn�✓,�3 <br />Federal 9 -digit Identification number: 59-60006764 -digit seg, code 070 <br />Authorized County Officia *Siature <br />' ' '*`� <br />June 4. 2024 <br />slate <br />_ Susan Adams Chairman�TAP. <br />6Y iqT; <br />Type or Print Name and Title •.9y �' <br />Sign and return this page with your application to: <br />Florida Department of Health <br />Emergency Medical Services Unit, Grants <br />4052 Bald Cypress Way, Bin A-22 <br />Tallahassee, Florida 32399-1722 <br />Do not write below this line. For use by State Emeraencv Medical Services Section <br />Grant Amount for State to Pay: $ <br />_Approved By: <br />Approved By: <br />Signature of State EMS Unit Supervisor <br />Grant ID: Code: <br />Date <br />Signature of Contract Manager Date <br />State Fiscal Year: 2023 - 2024 <br />Organization Code E.O. OCA Object Code Category <br />64-61-70-30-000 05 SF005 751000 059998 <br />Federal Tax ID: VF _ _ _ _ _ _ _ _ _ Seq. Code: <br />Grant Beginning Date: <br />Grant Ending Date: <br />DH 1767P, December 2008 (rev. June 8, 2018), incorporated by reference in F.A.C. 64J-1.015. <br />3 <br />